at Gibson Area Hospital & Health Services in Gibson City, Illinois, United States
Job Description
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.
Qualifications
PERFORMANCE EXPECTATIONS
1. Meet appeal submission timelines.
2. Maintain high appeal accuracy with minimal errors.
3. Achieve established appeal recovery and reimbursement goals.
4. Reduce preventable denials through trend identification and collaboration.
5. Maintain productivity standards for appeals completed and follow-up activities.
COMPENTENCIES
1. Revenue Cycle Knowledge: Understanding of the Revenue Cycle process including claims, payment posting, accounts receivable, denial management, and reimbursement processes.
2. Attention to Detail: Accurately enter demographics, insurance information, adjustments with minimal errors.
3. Analytical / Problem-Solving: Ability to investigate and identify application discrepancies and implement corrective actions.
4. Productivity & Time Management: Prioritizes workload, meets deadlines, and manages high volumes of applications efficiently.
5. Compliance & Confidentiality: Maintains HIPAA compliance and protects patient health information during billing and collections activities.
6. Communication Skills: Communicates professionally with patients, providers, insurance carriers, and coworkers.
7. Technology Proficiency: Experience with practice management systems, EHR/EMR platforms, clearinghouses, and software such as Microsoft Office/Excel.
8. Accountability / Ownership: Takes responsibility for assigned accounts, follows claims through resolution, and escalates issues appropriately.
9. Team Collaboration: Works effectively with providers, front office staff, billing office staff and leadership to improve reimbursement and workflow efficiency.
INFECTION EXPOSURE RISK LEVEL
Category 3 – No Risk – Your job does not involve exposure to blood, body fluids or tissue. You do not perform or help in emergency medical care or first aid as part of your job.
WORKING CONDITIONS
1. Works in a normal office where there are relatively few discomforts due to adverse or hazardous working conditions. There is some exposure to noise and personal space is limited.
2. Will work in an office with co-workers where traffic may be constant, subjecting your work to interruption, which can produce stress and fatigue.
