Appeals Specialist II - REMOTE

Benefits

• Comprehensive Health Coverage - Medical, dental, and vision plans to keep you and your family healthy.
• Future Security: 401(k) with matching
• Student Loan Support - Up to $10,000 repayment assistance, because we invest in your future.
• Educational Tuition Assistance
• Competitive Pay & Full Benefits - A salary and package designed to reward your expertise and dedication.

Job Summary

The Appeal Specialist II reviews, analyzes, and resolves insurance denials to ensure accurate reimbursement and regulatory compliance. This role logs and reviews denials for trend reporting, provides feedback to facilities, and communicates payer updates to relevant stakeholders. The Appeal Specialist II collaborates with internal teams to ensure timely and thorough appeal resolution and supports initiatives that improve denial prevention and recovery processes.

Essential Functions

• Files medical necessity and level of care appeals using MCG, InterQual, CMS, and other guidelines as needed. Files other clinical appeals on in scope denial types including, but not limited to denials surrounding readmissions, experimental and investigational determinations, and coverage based determinations.
• 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. Reports safety hazards and initiates appropriate action. Participates in safety instructional programs.
• Provides excellent customer service to patients, families, significant others, 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.

Qualifications

• Associate Degree in Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy required
• Bachelor's Degree in Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy preferred
• 3-5 years of experience in clinical operations 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

Knowledge, Skills and Abilities

• Basic knowledge of medical billing, coding systems, and insurance claim processes.
• Strong communication skills for interacting with insurance carriers, patient financial service units, and other departments.
• Detail-oriented, with strong organizational and time management skills to manage a high volume of appeals.
• Proficiency in using healthcare billing software and Google Suite.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
• PT - Physical Therapist required or
• OT - Occupational Therapist - Registered required or
• SLP - Speech Language Pathologist required

The Payment Compliance and Contract Management (PCCM) team plays a critical role in ensuring that payments are made according to contractual agreements and regulatory requirements. The team oversees the full contract lifecycle, focusing on analyzing reimbursement discrepancies, improving revenue cycle processes, and ensuring compliance with contract terms to support financial accuracy and operational efficiency.

Community Health Systems is one of the nation's leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 71 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.