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Appeals Specialist

4 months ago

Daytona Beach, United States Halifax Health Full time

Halifax Health is seeking an Appeals Specialist for the PBFS - Administration Department.


The Appeals Specialist is responsible for monitoring and tracking the status of appeals submitted by the Clinical Appeals Representative. The position involves but is not limited to reviewing incoming denials for appropriateness, documenting the denial specifics into the current software, follow up on expected reimbursement and assisting with report development. The Appeals Specialist also provides follow up on aging clinical accounts on the DNFB and the AR Report. The position provides assistance and support to the Clinical Appeals Representative and the Revenue Integrity Coordinator. The Appeals Specialist requires a strong knowledge of hospital billing and reimbursement. This position also coordinates with the outpatient oncology center for documenting and tracking the denials and appeal of outpatient services. The Appeals Specialist works collaboratively with the staff and management involved in key areas of the revenue cycle, Case Management and Health Information Management.


  • High School Diploma or GED equivalent required. Associate's degree preferred.
  • Two years of hospital collections, recovery or appeals processing experience preferred.
  • Experience with managed care, governmental and/or RAC appeal process preferred.
  • Ability to work independently and in a multi-disciplinary team.
  • Ability to work effectively and efficiently under tight deadlines, high volumes and multiple interruptions.
  • Ability to work collaboratively with other departments to positively affect clinical and financial outcomes.
  • Must have good PC knowledge and skills.
  • Must be able to work successfully in a “team-work” environment.
  • Excellent written and verbal communication skills.
  • Ability to communicate with multiple levels in the organization.
  • Critical thinking and analytical skills, problem solving skills, and the ability to prioritize and multi-task.

  • Review incoming denials that generate from remit codes, the in-house denial process, letters or other departments within the organization. Determine if appropriate for clinical appeal and assign to the Clinical Appeal Representative.
  • Open new denials in the current software, documentation should include type of denial, appeal due date, expected reimbursement and any pertinent information to assist with the appeal process.
  • Assist Clinical Appeal Representative to track and meet appeal deadlines.
  • Provide follow up and documentation of outgoing appeals submitted by the Clinical Appeal Representative.
  • Scan pertinent documentation regarding denials and appeals into the medical record.
  • Obtain case pertinent information from other departments, i.e. coding, billing and recovery.
  • Notify the Case Management Department of aging accounts holding on the DNFB waiting for authorization.
  • Communicate with Case Management regarding pending denials for patient’s that are in-house.
  • Work with the appeals department staff to identify opportunities to improve the physical workflow processes within the appeals department.
  • Work with the Revenue Integrity Coordinator to develop, maintain and prepare departmental reports.
  • Coordinate and communicate with the outpatient oncology staff for notification of new denials and to assist with documenting, tracking and follow up on all outpatient oncology appeals.
  • Verify Medicaid authorizations, document the authorization numbers in the current system, and notify billing to release the claim for reimbursement.
  • Attend and participate in departmental meetings.
  • Regularly makes complex decisions within the scope of the position and is comfortable working independently.
  • Complies with state and federal regulations, compliance requirements, Halifax Health policy and procedures, including those regarding fraud and abuse, confidentiality, and HIPPA.
  • Participates in professional development to enhance job knowledge and performance.
  • Demonstrates teamwork and integrity in all work related activities.
  • Other duties as assigned.

Recognized as one of the 50 Top Cardiovascular Hospitals™ in the United States by IBM Watson Health™, Halifax Health serves Volusia and Flagler counties, providing a continuum of health care services through a network of organizations including a tertiary hospital, two community hospitals, urgent care clinics, psychiatric services, a cancer treatment center with five outreach locations, the area’s largest hospice, a center for inpatient rehabilitation, outpatient rehabilitation clinics, primary care walk-in clinics, a clinic specializing in women’s health, a pediatric care community clinic, five pediatric medical practices, a home health care agency and an exclusive provider organization. Halifax Health offers the area’s only Level II Trauma Center, Thrombectomy-Capable Stroke Center (TSC), Center for Transplant Services, Pediatric Intensive Care Unit, Child and Adolescent Behavioral Services, complete Neurosurgical Services, OB Emergency Department and Level III Neonatal Intensive Care Unit that cares for babies born earlier than 28 weeks. For more information, visit halifaxhealth.org.