Patient Financial Services - Medical Appeals Specialist FT

JOB TITLE: PATIENT FINANCIAL SERVICES APPEALS SPECIALIST DEPARTMENT: PATIENT FINANCIAL SERVICES HOURS & SHIFT REQUIREMENTS: Regular full time, 40 hours weekly, Monday thru Friday, 8 – 4:30. General Summary The PFS Medical Appeals Specialist reviews patient medical records and clinical documentation to determine medical necessity and identify the basis for denied claims. The Specialist prepares formal, well-supported appeals and submits clinical documentation to maximize reimbursement while ensuring compliance with payer regulations and organizational policies. This position works with providers, nurses, paramedics, and other healthcare professionals to obtain supporting documentation for claims related to hospital, clinic, and ambulance services. The role requires strong knowledge of medical terminology, clinical procedures, medical billing and coding, insurance guidelines, and the ability to analyze clinical information and communicate findings effectively. GIBSON AREA HOSPITAL & HEALTH SERVICES MISSION STATEMENT To provide personalized, professional healthcare services to the residents of the Communities we serve. Principle Duties And Responsibilities Review patient medical records, clinical documentation, and patient care reports to determine medical necessity and support appeals. Review denied claims and identify the clinical and/or administrative basis for denial. Research payer policies, medical necessity guidelines, and coverage requirements. Prepare clear, thorough, and evidence-based appeal letters to maximize appropriate reimbursement. Select and submit complete medical records and supporting documentation with each appeal. Work with physicians, nurses, paramedics, and other clinical staff to obtain additional documentation or clarification. Review appeals for hospital, clinic, and ambulance services. Submit accurate and complete appeals within required payer deadlines. Follow up with insurance payers and monitor appeals through final resolution. Maintain accurate appeal records, documentation, and outcomes. Track reimbursement recovered and identify recurring denial trends and documentation issues. Communicate trends and opportunities for improvement to PFS and clinical leadership. Maintain current knowledge of Medicare, Medicaid, commercial payer requirements, and applicable clinical guidelines. Maintain patient confidentiality and comply with HIPAA and organizational policies. Demonstrate strong clinical judgment, critical thinking, attention to detail, and effective written and verbal communication. Maintain established productivity, quality, timeliness, and accuracy standards Physical Requirements Works requires the ability to lift and carry boxes weighing between 5 to 25 pounds. Physical strength to perform the following lifting tasks: Floor to Knuckle- 20 pounds 12” to Knuckle- 30 pounds Knuckle to Shoulder- 20 pounds Shoulder to Overhead- 10 pounds Carry 14ft.- 20 pounds Push 25ft.- 10 ft/lbs Pull 10 ft.- 10 ft/lbs Work required ability to stand up for fifteen minutes at a time. Work requires communication abilities necessary to gather and exchange information with all departments, including the ability to use a telephone. Work requires ability to use a computer. Work requires visual acuity necessary to observe and obtain information and use documentation. Auditory acuity to hear patient/family/others for purposes of communication. REPORTING RELATIONSHIP Reports to Director of Patient Financial Services and/or Director of Operations & Revenue Services.