PFS - Medical Appeals Specialist (Full time Onsite)

About the role

The PFS Medical Appeals Specialist analyzes patient records, writes formal arguments, prepares, submits, and tracks insurance claims to maximize reimbursement while ensuring compliance with payer regulations and organizational policies. The focus is on investigating claim errors, matching medical codes to payer rules, and submitting supporting clinical proof for claims related to Hospital, Clinic, and Ambulance services.

Responsibilities

• Prepare timely, well-supported appeals for submission to government and commercial payers.
• Collaborate with coding, patient accounts, collections, registration, and clinical departments to resolve recurring issues.
• Improve reimbursement outcomes while maintaining compliance with payer regulations and organizational policies.
• Research payer policies, contracts, medical necessity guidelines, and coverage criteria.
• Prepare and submit first-level, second-level, and external appeals within payer deadlines.
• Draft professional appeal letters supported by medical documentation, coding guidelines, payer policies, and regulatory requirements.
• Monitor appeal status and follow up with insurance companies until resolution.
• Maintain accurate documentation of appeal activity in the billing system.
• Escalate complex appeals to leadership when appropriate.
• Maintain productivity and quality standards established by the department.
• Stay current on payer policy changes, CPT, ICD-10-CM, HCPCS, and regulatory updates.
• Perform other duties as assigned.

Requirements

Physical Requirements

• 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 14 ft.: 20 pounds
  • Push 25 ft.: 10 ft/lbs
  • Pull 10 ft.: 10 ft/lbs
• Ability to stand for fifteen minutes at a time.
• Communication abilities to gather and exchange information with all departments, including telephone use.
• Ability to use a computer.
• Visual acuity to observe and obtain information and use documentation.
• Auditory acuity to hear patients, families, and others for communication purposes.

Performance Expectations

• Meet appeal submission timelines.
• Maintain high appeal accuracy with minimal errors.
• Achieve established appeal recovery and reimbursement goals.
• Reduce preventable denials through trend identification and collaboration.
• Maintain productivity standards for appeals completed and follow-up activities.

Competencies

• Revenue Cycle Knowledge: Understanding of the Revenue Cycle process including claims, payment posting, accounts receivable, denial management, and reimbursement processes.
• Attention to Detail: Accurately enter demographics, insurance information, adjustments with minimal errors.
• Analytical / Problem-Solving: Ability to investigate and identify application discrepancies and implement corrective actions.
• Productivity & Time Management: Prioritizes workload, meets deadlines, and manages high volumes efficiently.
• Compliance & Confidentiality: Maintains HIPAA compliance and protects patient health information during billing and collections activities.
• Communication Skills: Communicates professionally with patients, providers, insurance carriers, and coworkers.
• Technology Proficiency: Experience with practice management systems, EHR/EMR platforms, clearinghouses, and software such as Microsoft Office/Excel.
• Accountability / Ownership: Takes responsibility for assigned accounts, follows claims through resolution, and escalates issues appropriately.
• Team Collaboration: Works effectively with providers, front office staff, billing office staff, and leadership to improve reimbursement and workflow efficiency.

Working Conditions

• Works in a normal office environment with relatively few discomforts due to adverse or hazardous conditions.
• Some exposure to noise and limited personal space.
• Infection Exposure Risk Level: Category 3 (No Risk) – Job does not involve exposure to blood, body fluids, or tissue, nor does it involve emergency medical care or first aid.

Reporting Relationship

Reports to Director of Patient Financial Services and/or Director of Operations & Revenue Services.