Clinical Appeals Specialist

Job Description

Job Description

In this role, you will play a vital role in ensuring the accurate and timely review of insurance denials and appeals, advocating for our patients and healthcare providers. You will collaborate with healthcare providers and insurance companies to facilitate the clinical appeal process, utilizing your clinical expertise to support the necessity of medical services.

• Conduct thorough and accurate reviews of insurance denials and appeals

• Advocate for patients and healthcare providers by communicating and negotiating with insurance companies

• Utilize clinical knowledge and expertise to identify and resolve issues with clinical denials and appeals

• Collaborate with other members of your team to gather necessary information and documentation for appeal

• Ensure timely and accurate submission of clinical appeals

• Maintain detailed and organized documentation of denials and appeals processes

• Stay up-to-date on insurance policies and regulations to ensure compliance in appeals

• Communicate effectively with patients, healthcare providers, and insurance companies regarding denials and appeals

• Monitor and track the success rate of appeals and identify areas for improvement

• Adhere to ethical and legal standards in all aspects of the job

• Maintain confidentiality of patient information and adhere to HIPAA regulations

• Participate in meetings and committees related to denials and appeals

• Continuously seek opportunities to improve processes and efficiency

• Ensure timely and accurate reporting of denials and appeals to management

• Bachelors degree in Nursing, Health Administration, or a related field. Advanced clinical degrees preferred (e.g., RN, NP, PA)

• Minimum of 2 years of clinical experience in a healthcare setting

Experience in clinical appeals, pre-authorizations, utilization review, or case management is highly desirable

TRC Talent Solutions is proud to be an Equal Opportunity Employer (EOE). All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. At TRC, we take pride in fulfilling our opportunity to add value to our client's business as their staffing partner, while working tirelessly to connect thousands of individuals each year with work opportunities where they can meet the needs of their families and have the potential to build their careers.