Clinical Appeals Specialist

ADP, Inc.; Washington (District of Columbia); On-site; USD 65,000 - 90,000; Full time

Job summary

ADP, Inc. is seeking a clinical appeals specialist to review medical records and deny documentation and draft persuasive appeal letters. You will apply clinical judgment on medical necessity, ensure proper letter formats, and attach all required records within filing windows.

The role requires RN/NP/PA or equivalent licensure, knowledge of HIPAA, and experience with medical records and appeals processes. Collaboration with staff for training materials is included.

Qualifications

• Bachelor's Degree or equivalent combination of education and experience.
• Licensure as RN/NP/PA or other qualified healthcare provider.
• Knowledge of HIPAA and healthcare documentation requirements.
• Experience with medical records and appeals processes.
• Ability to prepare clear reports and train staff.
• Knowledge of data collection, reporting, and administrative processes.

Responsibilities

• Obtain and communicate claim notes using TimeMatters.
• Examine medical records and UB-04s to appeal denied claims.
• Apply clinical judgment on medical necessity and admissions.
• Draft, review, and revise appeal letters.
• Ensure letters follow guidelines and include attachments.
• Verify page citations align with records.
• Process timely appeals and follow-ups within filing periods.
• Maintain HIPAA compliance.
• Assist in training materials for staff.

Skills

Clinical knowledge

HIPAA compliance

Data systems literacy

Data collection & reporting

Report writing

Training & mentoring

Problem solving

Communication

TimeMatters usage

Education

Bachelor's Degree or equivalent

Licensed healthcare professional (RN/NP/PA etc.)

Tools

TimeMatters

Job description

ADP, Inc. is seeking a clinical appeals specialist to review medical records and deny documentation and draft persuasive appeal letters. You will apply clinical judgment on medical necessity, ensure proper letter formats, and attach all required records within filing windows.

The role requires RN/NP/PA or equivalent licensure, knowledge of HIPAA, and experience with medical records and appeals processes. Collaboration with staff for training materials is included.