Full-time Appeals Coordinator

Lexington Regional Health Center

Title: Appeals Coordinator

Date: July 7, 2025

Supervisor: Revenue Integrity Director

Department: Administration

FLSA Status: Non-Exempt

Principle duties and responsibilities

1. Assists the team in denial avoidance and cash conversion strategies through the development of new and innovative methods and processes. 
2. Reviews contract language as necessary to resolve denied claims including both inpatient and outpatient. 
3. Reviews first and second level appeals for medical necessity, completes a comprehensive medical necessity packet summarizing clinicals facts for the Chief Medical Officer and Utilization Review department to review. 
4. Reviews medical records using evidence based medical criteria. 
5. Responds to members and/or providers in writing with the results of the appeal review in accordance with compliance and grievance department standards and applicable regulatory requirements. 
6. Provides knowledge and expertise related to third-party government and non-government payer clinical denials and appeals process. 
7. Coordinates collaboration and peer-to-peer appeals with the site provider advisors to ensure deadlines are not missed. 
8. Utilizes payer administrative manuals to dispute denied claims. 
9. Combines strong relationship building skills and clinical knowledge to manage the authorization and appeals management process. 
10. Responsible for investigating and processing appeal requests and authorizations.
11. Reviews prospective, retrospective or concurrent medical records of denied services for medical necessity.  
12. Serves as a liaison with the Business Office, Administration and other departments as applicable.  
13. Coordinates the managed care determinations and distributes information to the admissions support staff. 
14. Contacts appropriate parties (internal and/or external) as needed for additional information to properly formulate the clinical appeal. 
15. Determines root cause of each denial and applies company-specific coding for trending and analysis.
16. Compiles all the required annual training to support providers and coders. 
17. Facilitates the local appeal process for medical and experimental denials.
18. Stays current with Federal and State regulations regarding medical necessity for inpatient and observation hospitalizations. Provides feedback to providers and nursing staff related to patient status.
19. Proactively manages all relevant portals to ensure the prompt and efficient retrieval of specific medical records. Highlights critical information within the records to facilitate timely review and support accurate, on-time payment processing.
20. Assists with education to providers to enhance documentation for Evaluation and Management (E&M) placement. 
21. Follows up to ensure appeals and disputes are received and reviewed prior to timely filing.
22. Works appeals until all exhausted options have been met. 
23. Works as a liaison between insurance company’s representatives and billing departments. 
24. Assists and educates providers to ensure maximum documentation to maximize revenue potential. 
25. Serves as a back up to Utilization Review and Prior Authorization departments, as needed. 
26. Provides updates and insight to reduce denials and improve revenue cycle performance to senior leader and/or the senior leadership team.
27. Work with Information Technology (IT) and other departments as an Informatics nurse liaison.
28. Responsible for reviewing documentation of clinical appeals, highlighting pertinent information and sending only the required documentation to insurance companies. 
29. Supports IT and Nursing with informatics education and training.
30. Ensures patients and visitors follow current infection control guidelines. 
31. Responsible for ensuring the environment meets appropriate governing body standards.
32. Duties that could include blood exposure and risk to bloodborne pathogens (eg: lacerations, handling of blood-contaminated items, etc.)
33. Maintains patient and staff safety through the use of patient safety tools (Teamstepps, Just Culture, etc.).
34. Regular attendance at the assigned work location is required.
35. Performs other duties as assigned.

Minimum knowledge, skills, and abilities

1. Knowledge of financial healthcare reimbursement analysis, including an understanding of diagnosis and procedure coding, billing practices, and payment methodologies; ability to use computer and office equipment and carry out duties as is typically acquired through the completion of a Bachelor’s degree in business administration, finance, healthcare or related field or five years equivalent experience preferred. Knowledge and understanding of nursing theory and practice and the growth and development of a variety of patients in order to meet the patients' health care needs as is typically acquired through the completion of an Associate's or Bachelor's degree in Nursing from an accredited school. Bachelor's degree preferred. 
2. Must hold a current active Registered Nurse license from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. 
3. Three years of experience of working with insurance companies’ denial and appeal processes required. 
4. Five years of experience of case management and Utilization Review required.  
5. Minimum of three years’ experience of inpatient authorizations preferred.
6. Three years of experience and knowledge of Medicare inpatient only list required.
7. Three years of proficient experience of inpatient status management preferred. 
8. Maintains and applies understanding of federal, state and local rules and regulations impacting denials and appeals.
9. Strong critical thinking, analytical and research skills along with the ability to adapt to change and work in a high-volume environment.
10. Ability to learn different systems and tools as necessary.
11. Prior experience working with Medicare Advantage appeals preferred.
12. Ability to work under tight deadlines and manage stressful situations.
13. Knowledge of Medicaid/Medicare hearing and appeals. 
14. Prior experience with Implementing new software tools and workflows preferred.
15. Three years’ strategic planning experience preferred to identify and operationalize initiatives related to denials management processes and workflows. 
16. Serve as a subject matter expert in Utilization Review to maximize revenue potential regarding status management.
17. Serves as a subject matter expert in the two midnight Medicare Rule.
18. Strong critical thinking, analytical and research skills along with the ability to adapt to change and work in a high-volume environment.
19. Must have excellent time management skills.
20. Knowledge of third-party and insurance company operating procedures, regulations and billing requirements, and government reimbursement programs. 
21. Knowledge of CMS and payer regulatory requirements as it pertains to hospital and professional charging and billing practices.  
22. Understanding and working knowledge of hospital charge master and department charging practices.  
23. Understanding of and ability to resolve denials through review of payer policy and contracts with system updates or effective appeal processes.  
24. Ability to work with prior authorization and case management teams to implement processes and strategies to reduce denials.  
25. Ability to solve problems and engage independent critical thinking skills. 
26. Ability to understand and translate operational knowledge to identify unusual payer circumstances, trends, or activity.  
27. Ability to evaluate and enforce negotiated contract rates and terms in collaboration with revenue cycle partners.  
28. Ability to lead, coordinate, and organize tasks and projects through various complex and challenging situations to completion under time-sensitive deadlines.  
29. Ability to maintain attention to detail and concentration for long periods of time.  
30. Ability to synthesize, coordinate, and analyze data to identify opportunities to automate simple and repetitive tasks.  
31. Ability to maintain a work pace appropriate to given workload, to perform complex and varied tasks, and to understand and remember detailed instructions. 
32. Ability to make independent decisions and/or exercise judgment based on appropriate information.  
33. Ability to recommend operational and management decisions in response to changing conditions. 
34. Ability to communicate effectively both verbally and in writing. 
35. Ability to establish and maintain effective working relationships with all levels of personnel. 
36. Ability to maintain confidentiality relevant to sensitive information.
37. Successful completion of required knowledge and training of standard precaution protocols and when to apply during principle duties and responsibilities.

Working Conditions

1. Works in a normal office work environment with little exposure to excessive noise, dust, temperature, etc.
2. Spends up to 75% of shift sitting whether completing deskwork or in meetings. Required to ambulate up to 500 feet at one time within facility for attending meetings. Required to file paperwork, including lifting files weighing up to 20 pounds to place in storage cabinets and transporting files up to 500 feet within office and facility.  
3. Remote work, except for occasion onsite meetings and training.  

Management responsibilities

None.

____________________________________________________________________________________

Job description statements are intended to describe the general nature and level of work being performed by employees assigned to this job title. They are not intended to be a complete list of all responsibilities, duties and skills required.