Clinical Appeal Specialist

As a Clinical Appeal Specialist, you will play a key role in managing healthcare denials, appeals, and reimbursement recovery processes within a complex clinical environment. You will help ensure that medical claims are accurately reviewed, appropriately reimbursed, and aligned with applicable healthcare regulations and payer requirements. Working closely with clinical, financial, and administrative teams, you will investigate denied claims, identify underlying issues, and develop effective appeal strategies. Your expertise in healthcare reimbursement, medical coding, and insurance policies will contribute to improving financial outcomes and reducing recurring denials. You will also analyze denial trends and recommend process improvements to strengthen revenue cycle performance. This is an opportunity to combine clinical knowledge, analytical thinking, and attention to detail in a fully remote-eligible position.

• Associate's degree in Healthcare, Finance, or a related field is required.

• Alternatively, candidates must meet one of the following educational and professional experience pathways:

  • Bachelor's degree combined with at least five years of healthcare experience and an active Registered Nurse (RN) license.

  • Associate's degree combined with at least seven years of healthcare experience, preferably in nursing, and an active RN license.

• Active RN licensure is required. Current LPNs working in Clinical Denial Specialist positions may be eligible for a two-year period to obtain RN licensure.

• Strong knowledge of healthcare reimbursement, including benefit investigations, payer reimbursement policies, regulatory requirements, and administrative procedures.

• Understanding of Medicare, Medicaid, managed care organizations, third-party reimbursement, and insurance payer structures.

• Experience with hospital and insurance reimbursement processes, medical billing concepts, and regulations governing payment compliance, denials, and appeals.

• Proficiency in reimbursement methodologies, including per-diem, Diagnosis-Related Groups (DRG), fee schedules, percentage of charges, and stop-loss arrangements.

• Knowledge of medical coding systems and their impact on claims adjudication, including ICD, CPT, HCPCS, DRG, APG, APC, and revenue codes.

• Strong financial data analysis skills, with the ability to interpret reimbursement information and identify trends and discrepancies.

• Computer proficiency, including intermediate Microsoft Excel skills and familiarity with Microsoft Office applications and Microsoft Access.

• Excellent written and verbal communication skills, with the ability to explain complex reimbursement matters clearly and professionally.

• Strong analytical, investigative, and problem-solving abilities, with exceptional attention to detail and accuracy.

• Ability to work independently and collaboratively while managing multiple priorities and meeting deadlines.

• Proactive mindset, with the ability to anticipate obstacles, identify operational challenges, and recommend effective process improvements.

Preferred qualifications:

• Experience in oncology nursing or within an oncology healthcare environment.

• Background in utilization review, quality management, or recent case management.

• Previous experience using Soarian or similar healthcare information and reimbursement systems.