PFS - Medical Appeals Specialist FT

JOB TITLE: PATIENT FINANCIAL SERVICES MEDICAL 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 is responsible for analyzing patient records, writing formal arguments, preparing, submitting and tracking insurance claims to maximize reimbursement while ensuring compliance with payer regulations and organizational policies.
The focus would be on investigating claim errors, matching medical codes to payer rules, and submitting supporting clinical proof for claims related to Hospital, Clinic and Ambulance services.
This role requires strong knowledge of medical billing, coding, insurance guidelines, and excellent analytical and communication skills.

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

PHYSICAL REQUIREMENTS
1. Works requires the ability to lift and carry boxes weighing between 5 to 25 pounds.
2. Physical strength to perform the following lifting tasks:
a. Floor to Knuckle- 20 pounds
b. 12” to Knuckle- 30 pounds
c. Knuckle to Shoulder- 20 pounds
d. Shoulder to Overhead- 10 pounds
e. Carry 14ft.- 20 pounds
f. Push 25ft.- 10 ft/lbs
g. Pull 10 ft.- 10 ft/lbs
3. Work required ability to stand up for fifteen minutes at a time.
4. Work requires communication abilities necessary to gather and exchange information with all departments, including the ability to use a telephone.
5. Work requires ability to use a computer.
6. Work requires visual acuity necessary to observe and obtain information and use documentation.
7. 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.