Clinical Appeal Specialist in United States at Jobgether

This position is listed on behalf of a partner company, which manages all applications and next steps. Our partner is looking for a Clinical Appeal Specialist based in the United States.

As a Clinical Appeal Specialist, you will play a key role in managing healthcare denials, appeals, and reimbursement recovery processes within a complex clinical environment. You will help ensure that medical claims are accurately reviewed, appropriately reimbursed, and aligned with applicable healthcare regulations and payer requirements. Working closely with clinical, financial, and administrative teams, you will investigate denied claims, identify underlying issues, and develop effective appeal strategies. Your expertise in healthcare reimbursement, medical coding, and insurance policies will contribute to improving financial outcomes and reducing recurring denials. You will also analyze denial trends and recommend process improvements to strengthen revenue cycle performance. This is an opportunity to combine clinical knowledge, analytical thinking, and attention to detail in a fully remote-eligible position.

• Coordinate and administer the end-to-end denials review and appeals management processes, including denial management, claims recovery, and root cause analysis.

• Review denied healthcare claims, investigate reimbursement issues, and identify opportunities for successful appeals and financial recovery.

• Analyze payer policies, reimbursement methodologies, regulatory requirements, and administrative rules to determine appropriate appeal strategies.

• Evaluate medical documentation, billing information, and coding accuracy to support claims adjudication and reimbursement compliance.

• Apply knowledge of Medicare, Medicaid, commercial insurance, and managed care requirements when reviewing claims and resolving reimbursement disputes.

• Identify recurring denial patterns, investigate underlying causes, and recommend corrective actions to improve reimbursement processes and operational efficiency.

• Monitor reimbursement practices and ensure compliance with applicable healthcare regulations, billing requirements, and coding guidelines.

• Use financial data and reporting tools to evaluate denial trends, track recovery performance, and support informed decision-making.

• Collaborate with clinical, financial, case management, and other internal stakeholders to resolve complex reimbursement and appeals issues.

• Maintain accurate documentation and ensure appeals and related assignments are completed within established timelines.

• Identify operational barriers and improvement opportunities, proactively recommending solutions that enhance the effectiveness of the revenue cycle.

• Associate's degree in Healthcare, Finance, or a related field is required.

• Alternatively, candidates must meet one of the following educational and professional experience pathways:

  • Bachelor's degree combined with at least five years of healthcare experience and an active Registered Nurse (RN) license.

  • Associate's degree combined with at least seven years of healthcare experience, preferably in nursing, and an active RN license.

• Active RN licensure is required. Current LPNs working in Clinical Denial Specialist positions may be eligible for a two-year period to obtain RN licensure.

• Strong knowledge of healthcare reimbursement, including benefit investigations, payer reimbursement policies, regulatory requirements, and administrative procedures.

• Understanding of Medicare, Medicaid, managed care organizations, third-party reimbursement, and insurance payer structures.

• Experience with hospital and insurance reimbursement processes, medical billing concepts, and regulations governing payment compliance, denials, and appeals.

• Proficiency in reimbursement methodologies, including per-diem, Diagnosis-Related Groups (DRG), fee schedules, percentage of charges, and stop-loss arrangements.

• Knowledge of medical coding systems and their impact on claims adjudication, including ICD, CPT, HCPCS, DRG, APG, APC, and revenue codes.

• Strong financial data analysis skills, with the ability to interpret reimbursement information and identify trends and discrepancies.

• Computer proficiency, including intermediate Microsoft Excel skills and familiarity with Microsoft Office applications and Microsoft Access.

• Excellent written and verbal communication skills, with the ability to explain complex reimbursement matters clearly and professionally.

• Strong analytical, investigative, and problem-solving abilities, with exceptional attention to detail and accuracy.

• Ability to work independently and collaboratively while managing multiple priorities and meeting deadlines.

• Proactive mindset, with the ability to anticipate obstacles, identify operational challenges, and recommend effective process improvements.

Preferred qualifications:

• Experience in oncology nursing or within an oncology healthcare environment.

• Background in utilization review, quality management, or recent case management.

• Previous experience using Soarian or similar healthcare information and reimbursement systems.

• Annualized salary range: $31.99–$48.80 per hour, depending on qualifications, experience, skills, education, location, and internal compensation considerations.

• Fully remote-eligible working arrangement.

• Opportunity to contribute to a meaningful healthcare mission focused on improving patient outcomes and supporting cancer care.

• Collaborative professional environment bringing together clinical, financial, and administrative expertise.

• Opportunity to apply and develop specialized knowledge in healthcare reimbursement, claims recovery, and clinical appeals.

• Equal employment opportunities and reasonable accommodations throughout the recruitment and employment process.