Clinical Appeals Coordinator Job at Robert Half (Eden Prairie)

Clinical Denials Audit & Analysis Specialist

Baptist Health is looking to add a Clinical Denials Audit & Analysis Specialist ...

Location

United States , Jacksonville

Salary:

Not provided

Baptist Health (Florida)

Expiration Date

Until further notice

Requirements

1-2 Years Denial/Audit Resolution Required
1-2 Years EMR Experience Required
1-2 Years Clerical Experience Required
1-2 Years Healthcare Experience Preferred
High School Diploma Preferred

Job Responsibility

Provides system support for Clinical Denials Audit and Analysis team
Works closely with the Denials and Appeals Nurses, Physician Advisors, and CDAA leadership to ensure denials are coordinated and escalations addressed
Responsible for entry of and follow up on concurrent (in-house) denials via the Epic Environment
Provides coordination for Medicare Discharge Appeals and coordinates with Utilization Management regarding outcomes
Schedules and provides clerical support to Physician Advisors for Peer to Peer and payer escalation requests
Provides clerical support to the Denials and Appeals Nurses as required
Coordination of multiple requests and denials received via voicemail, fax, and department Outlook mailbox

Fulltime

Medical Biller

We are looking for an experienced Medical Biller/ AR specializing in medical ope...

Location

United States , Scranton

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Extensive experience in medical billing and collections
Proficiency in multi-specialty coding practices
Certified Coding credentials are required
Familiarity with federal and state medical billing regulations
Strong analytical skills for trend analysis and audit processes
Proven ability to supervise and manage billing teams effectively
Excellent communication skills for collaboration with healthcare providers and payers
Attention to detail and commitment to maintaining data accuracy

Job Responsibility

Perform multi-specialty coding with precision to ensure timely submission of claims
Coordinate with clinical teams to address claim appeals, denials, and resolutions effectively
Develop and implement an audit process to validate clinical documentation and coded data integrity
Provide prompt responses to inquiries from patients, payers, and staff regarding claims and account submissions
Supervise the daily tasks of billing specialists to maintain workflow efficiency
Monitor accounts receivable over 120 days and implement strategies to reduce outstanding balances
Conduct trend analysis to ensure compliance with payer reimbursement agreements and resolve discrepancies
Prepare and analyze monthly aging reports to support financial oversight
Establish best practices to uphold data integrity and quality throughout the revenue cycle
Lead staff training initiatives to promote adherence to industry standards and compliance requirements

What we offer

medical, vision, dental, and life and disability insurance
eligible to enroll in our company 401(k) plan

Appeals Specialist I

Responsible for all activities associated with requests for Provider Billing Dis...

Location

United States , Portland

Salary:

25.00 - 30.00 USD / Hour

Apex Systems

Expiration Date

Until further notice

Requirements

Excellent verbal and written communication skills
Intermediate computer skills (e.g. Microsoft Word, Excel, Outlook)
Knowledge of medical terminology, anatomy and coding (CPT, DX, HCPCs)
Knowledge of claims processing and clinical services operations
Demonstrated initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing a course of action
Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all aspects of internal and external contacts
Ability to present complex medical and reimbursement information to others and to be diplomatic and persuasive regarding health plan benefits, claims and eligibility
Ability to switch from one task or type of work to another as the business needs require
Ability to effectively prioritize work to meet strict timelines while maintaining quality and consumer centric focus
High school diploma or GED and a minimum 4 years’ experience in customer Service, Claims, or Clinical Services or equivalent combination of education and work experience

Job Responsibility

Responsible for all activities associated with appeal analysis, decision-making and closure
Appeal Intake – Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal. Document information in appropriate system
Appeal Analysis – Review claim coding and claim processing history, medical policy and reimbursement policies, regulatory and legal requirements, benefit contracts, and/or provider contracts. Collect and catalogue supporting documentation and formulate an appeal recommendation. Document information in appropriate system. Apply knowledge and experience to answer a variety of increasingly complex inquiries from members, providers, and provider representatives. Collaborate effectively with coding specialists, appeal nurses, physician reviewers, and others as necessary to reach timely decisions on appeals
Decision & Closure – Make non-clinical appeal determinations as permitted by department business processes and guidelines. Follow department’s processes to receive a clinical review and decision from licensed health professionals. Present complex cases to appeal panels, document decisions, communicate determinations to members, providers or their representatives. Document information in appropriate system(s)
External review process – Oversee set-up of appeals for external review organizations, including document collection and coordination, communication with all parties, and other responsibilities as an intermediary between the provider and the external review organization. Ensure external review information is documented in appropriate system. Prepares letters and cases for external review as needed. Implement external review decisions
Interpersonal and Communication – Provide information, education and assistance to members, providers, and their representatives. Facilitate the member’s or provider’s’ understanding of the appeal process and of the information necessary to effectively process an appeal. Be a courteous advocate to the member or provider when requesting supporting information. Work cooperatively and effectively across all business areas to resolve
Systems and data – Track appeals in appropriate systems and assist in the maintenance of files. Assist with compilation of reports on appeals, including trends, number of cases, decisions, suggestions for process improvement, types of appeals, and compliance with timelines
Support, apply and promote Provider or Member Appeal Policies & Procedures
Adhere to dependability, customer focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all work
Manage a defined caseload within department productivity and quality expectations and provide back up for other appeals staff

What we offer

Medical, dental, vision, life, disability, and other insurance plans
ESPP (employee stock purchase program)
401K program with company match after 12 months
HSA (Health Savings Account on the HDHP plan)
SupportLinc Employee Assistance Program (EAP) with up to 8 free counseling sessions
Corporate discount savings program
On-demand training program
Access to certification prep and a library of technical and leadership courses/books/seminars after 6+ months of tenure
Certification discounts and other perks to associations that include CompTIA and IIBA
Dedicated customer service team for Consultants

Fulltime

Surgery Medical Biller/Collections Specialist

This Surgery Medical Biller/Collections Specialist involves managing claim submi...

Location

United States , Los Angeles

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Minimum of 3–5 years of experience in healthcare billing, claims follow-up, and denial management
At least 2 years of hands-on experience with Epic billing workflows and denial resolution processes
Comprehensive understanding of payer guidelines, claim submission protocols, and appeal procedures
Strong attention to detail and the ability to accurately manage complex billing tasks
Proven organizational skills with the ability to prioritize multiple responsibilities
Expertise in medical billing, collections, denials, appeals, and ambulatory surgery
Familiarity with compliance standards and regulations governing medical records
Ability to collaborate effectively with multiple teams to achieve billing accuracy and reimbursement goals

Job Responsibility

Address and correct front-end edits and clearinghouse errors to facilitate clean claim processing
AR Insurance follow up via phone and online web portals
Submit electronic claims in compliance with specific payer guidelines and requirements
Manage timely corrections, rebills, and resubmissions of claims to resolve outstanding issues
Handle claim attachments and supporting documentation to meet payer requirements
Investigate and resolve denials by preparing appeals with appropriate clinical, coding, and billing documentation
Coordinate outreach to payers for unresolved or aged claims and follow up on outstanding accounts
Collaborate with patient access and coding teams to address discrepancies and ensure billing accuracy
Monitor payer trends, escalate systemic issues, and recommend improvements to prevent recurring denials
Verify patient information, including demographics, insurance coverage, and authorization details, to ensure claims are accurate before submission

What we offer

medical, vision, dental, and life and disability insurance
eligible to enroll in our company 401(k) plan

A&G RN Coordinator

The RN Coordinator will investigate and respond to written and/or verbal clinica...

Location

United States , New York

Salary:

110000.00 - 120000.00 USD / Year

MJHS

Expiration Date

Until further notice

Requirements

Graduate of accredited nursing program
BSN preferred
2 years managed care or hospital based utilization/case management experience
2 years minimum clinical experience
Licensed nurse in New York State
Proficiency with Microsoft Word, Excel, Power Point and Outlook is required
Must have excellent written and verbal communication skills
Must be comfortable researching current evidence based practice guidelines and protocols
Must be able to multi-task and managed multiple projects efficiently, meet deadlines, demonstrate analytical/critical thinking skills, and provide excellent customer services that leads to positive problem resolution

Job Responsibility

Investigate and respond to written and/or verbal clinical appeals, expedited clinical grievances and potential quality of care grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS (Centers for Medicare & Medicaid Services), and DOH (Department of Health) regulations
Determines types of reconsiderations, redeterminations, action appeals, grievances, and grievance appeal
Investigation of Provider, Subscriber, Membership and Pharmacy Appeals to include: Reimbursement, Coding, Benefits, Pre-existing Conditions, Prior Approval, Medical Necessity, Precertification, Continued Stay, Reduction, Termination, and Suspension of services
Investigate and respond to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations
Documents all relevant information in the Appeals and Grievances determination process in the appropriate designated areas
Tracks departments’ compliance with requested action as a component of the Appeals and Grievances determination process
Presents cases to Appeals & Grievances File Review
Attend and represent A&G at NYS Fair Hearings/OTDA/ALJ Hearing as required

What we offer

Sign-on Bonuses OR Student Loan Assistance for clinical staff
FREE Online RN to BSN and MSN degree programs
Tuition Reimbursement for all full and part-time staff
Dependent Tuition Reimbursement for clinical staff
Generous paid time off, including your birthday
Affordable and comprehensive medical, dental and vision coverage for employee and family members
Two retirement plans! 403(b) AND Employer Paid Pension
Flexible spending

Fulltime

Behavioral Health Coordinator

Baptist Behavioral Health – Southbank is seeking a highly organized and patient-...

Location

United States , Jacksonville

Salary:

Not provided

Baptist Health (Florida)

Expiration Date

Until further notice

Requirements

1-2 years Physician Office Experience Required
1-2 years Training Experience Required
1-2 years Clerical Experience Required
Less than 1 year Transcranial Magnetic Stimulation experience Preferred
Less than 1 year EPIC Experience Required
High School Diploma (required)
Associate of Arts/Science (preferred)
Basic Life Support (BLS) required

Job Responsibility

Set up and operate the NeuroStar TMS device, ensuring accurate coil placement, patient comfort, and adherence to safety protocols
Monitor patients during treatment sessions
explain procedures, administer psychiatric rating scales, and provide patient education on expectations and aftercare
Document treatments in TrakStar and Epic, including device parameters, patient tolerance, safety checks, and any adverse events
Verify insurance coverage and obtain prior authorizations
Schedule referral intakes, mapping sessions, daily treatments, and manage appeals for TMS and nasal spray therapies
Coordinate medication shipments and monitor supply levels to prevent shortages of medications and TMS supplies
Provide front desk coverage as needed, including patient check-in/out, co-pay collection, phone management, faxing, and responding to inquiries
Conduct appointment reminders, follow-up calls, and outreach to patients who miss sessions
Assist with community outreach events and educational sessions to promote awareness of available treatment options

Fulltime

Medical Billing and Coding Specialist

Fairweather Medical is seeking an experienced Medical Billing & Coding Specialis...

Location

United States , Anchorage

Salary:

Not provided

Doyon

Expiration Date

Until further notice

Requirements

3–5 years of medical billing and coding experience required
Strong working knowledge of CPT, ICD-10, and HCPCS coding
Experience billing commercial insurance plans (Alaska payer experience a plus)
Experience with urgent care, primary care, occupational health, or outpatient clinic billing preferred
Proficiency with EHR and billing systems
Strong attention to detail, organization, and follow-through
Ability to work independently while collaborating with a team

Job Responsibility

Submit and manage medical claims for insurance, employer-paid, and self-pay services
Review, code, and audit CPT, ICD-10, and HCPCS codes for accuracy and compliance
Manage claim follow-up, denials, and appeals to ensure timely reimbursement
Post payments, reconcile EOBs, and identify underpayments
Coordinate with clinical and administrative teams to resolve documentation issues
Maintain compliance with payer rules, billing guidelines, and internal policies
Assist with payer credentialing, fee schedule review, and billing process improvements

What we offer

Part-time position with flexibility and growth potential
Opportunity to transition to full-time as the role expands
Stable, locally based healthcare organization
Collaborative team environment with leadership access
Competitive hourly pay based on experience

Parttime

Manager, Utilization Review

Manager, Utilization Review for Care Management, remote in the United States. Pe...

Location

United States

Salary:

95000.00 - 105000.00 USD / Year

Personify Health

Expiration Date

Until further notice

Requirements

Current, unrestricted RN license in the United States or U.S. territory (compact license acceptable where applicable)
Graduate of an accredited nursing program (ADN or diploma required
BSN preferred)
Knowledgeable of the Federal, State, DMHC, CMS and ERISA regulations
1-2 years in care management, utilization management, discharge planning, or related clinical coordination
Minimum 1 year of compliance related experience preferred
Certification in Case Management or Utilization Review preferred but not required
1+ year of informal leadership (preceptor/mentor/lead) or some direct people leadership
Working understanding of HIPAA, member rights, scope of practice, and documentation requirements
Comfort following policies and escalating risk/safety concerns appropriately

Job Responsibility

Supervise day-to-day operations of assigned Utilization Management staff, including scheduling, workload distribution, and adherence to established workflows
Provide full people management for assigned Utilization Management teams, including hiring, performance management, and staff development
Provide routine coaching, feedback, auditing, support and disciplinary action to ensure productivity, quality, and timeliness standards are met
Participate in hiring, onboarding, and training of Utilization Management staff
Monitor documentation for completeness, accuracy, timeliness and compliance with company policies and regulatory requirements
Escalate clinical, operational, and performance issues appropriately to leadership
Reinforce policies, procedures, and clinical guidelines through regular communication and staff education
Support audit readiness by ensuring staff compliance with documentation and timeliness standards
Maintain HIPAA compliance, confidentiality, and minimum necessary access at all times
Solid knowledge and understanding of medical necessity criteria across inpatient, outpatient, concurrent, and retrospective reviews, with the ability to coach staff on clinical rationale, documentation quality and timeliness

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions
Unlimited PTO
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets

Fulltime

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Clinical Appeals Coordinator

Job Description

Job Responsibility

Requirements

What we offer

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