Clinical Appeals Specialist

We are seeking a Clinical Appeals Specialist to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Clinical Appeals Specialist plays an essential role managing and resolving clinical appeals related to insurance claims and member care. The Clinical Appeals Specialist ensures that appeals are thoroughly reviewed, accurately documented, and effectively communicated to insurance providers, healthcare professionals, and members. The Clinical Appeals Specialist collaborates closely with clinical teams to gather necessary medical information and supports the appeals process by interpreting clinical guidelines and insurance policies. The goal is to facilitate timely outcomes that uphold member rights and optimize reimbursement for healthcare services. The Clinical Appeals Specialist requires a detail-oriented professional who can navigate complex regulatory environments while maintaining a member-centered approach.

Minimum Qualifications:

• Bachelor's degree in Health Administration, Nursing, or a related healthcare field.
• 2 years experience in clinical appeals, medical billing, or healthcare claims processing.
• Strong understanding of medical terminology, clinical documentation, and insurance claim procedures.
• Proficiency with electronic health records (EHR) systems and claims management software.
• Excellent written and verbal communication skills. Bilingual (English/Spanish) preferred.

Preferred Qualifications:

• Master's degree in Health Administration, Nursing, or a related healthcare field.
• Certification in Medical Coding (e.g., CPC, CCS) or Healthcare Compliance.
• Experience working within a health insurance company or healthcare provider setting.
• Familiarity with regulatory standards such as Florida Medicaid, CMS and HIPAA guidelines.
• Advanced knowledge of clinical guidelines and payer policies related to appeals.
• Demonstrated ability to manage multiple appeals simultaneously in a fast-paced environment.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Review and analyze denied or disputed clinical claims to determine the validity and grounds for appeal.
• Gather and organize relevant clinical documentation, including medical records and physician notes, to support the appeals process.
• Prepare and submit timely comprehensive appeal letters and supporting documentation to the appealing party.
• Communicate effectively with internal and external stakeholders to clarify appeal status and or answer questions.
• Maintain accurate records of all appeals activities and track outcomes to ensure compliance with regulatory requirements and internal policies.
• Monitor the status of appeals, follow up with the appealing party to ensure timely resolution of cases.
• Collaborate with clinical and administrative teams to improve processes and reduce the frequency of claim denials.
• Perform other duties as assigned.