Clinical Appeals Specialist II - RN/PT/OT/SLP

CHS Career Site; United States; Remote; USD 65,000 - 85,000; Full time

Benefits offered by this job

401(k) matching

Student loan support (up to $10,000)

Tuition assistance

Health coverage

Paid time off

Job summary

Community Health Systems, Inc. is seeking an Appeal Specialist II to review, analyze, and resolve insurance denials to ensure accurate reimbursement and regulatory compliance. The role logs denials for trend reporting, provides feedback to facilities, and communicates payer updates to stakeholders.

It collaborates with internal teams to improve denial prevention and recovery processes. The position emphasizes handling appeals using MCG and InterQual guidelines, monitoring denial trends,

Qualifications

• Associate degree required in nursing or therapy field.
• Bachelor's degree in nursing, physical therapy, occupational therapy, or speech therapy preferred.
• 3–5 years of clinical operations experience in Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy required.
• 1–3 years of experience in claims processing, healthcare billing, or revenue cycle management preferred.
• 1–3 years of experience in utilization review and/or case management experience leveraging MCG or InterQual preferred.

Responsibilities

• Files medical necessity and level of care appeals using guidelines such as MCG, InterQual, CMS, and other guidelines as needed.
• Monitors clinical appeal processes for issues and trends and provides guidance and feedback to related departments as needed.
• Tracks and manages clinical denials using current tools (manuals, training programs).
• Identifies patterns and trends in denials; communicates to appropriate persons.
• Maintains documentation regarding all payer resources regarding denials and appeals processes.
• Understands and applies CHS Appeal Process for denied claims.
• Follows and enforces accepted safety practices for patients and the hospital.
• Provides excellent customer service to patients, families, physicians, coworkers, and external vendors by communicating professionally, responding promptly to inquiries, and fostering positive working relationships.
• Documents all actions accordingly by documentation standards within Artiva, HMS and other business office systems as required.
• Understands and applies policy and procedure manuals and other reference materials from insurance companies, regulatory organizations, and other in scope applicable entities.
• Ensures confidentiality of all patient accounts by following HIPAA guidelines.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Skills

Medical billing

Insurance claims

Communication skills

Attention to detail

Google Workspace

Healthcare billing software

Education

Associate Degree in Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy

Bachelor's Degree preferred

Tools

Healthcare billing software

Google Suite

Job description

Community Health Systems, Inc. is seeking an Appeal Specialist II to review, analyze, and resolve insurance denials to ensure accurate reimbursement and regulatory compliance. The role logs denials for trend reporting, provides feedback to facilities, and communicates payer updates to stakeholders.

It collaborates with internal teams to improve denial prevention and recovery processes. The position emphasizes handling appeals using MCG and InterQual guidelines, monitoring denial trends,