Clinical Appeal Specialist

Description

White Rock Medical Center is a community-based hospital located near the historic White Rock Lake community, that serves the Dallas, Garland, Mesquite and surrounding areas. We specialize in a wide range of services including comprehensive medical/surgical care, bariatric, cardiology, outpatient and emergency medicine.

Our mission is to deliver exceptional healthcare with compassion and excellence.

White Rock Medical Center is seeking compassionate, care-minded individuals to join our company and make a difference. As a member of the White Rock Medical Center team, you can advance your skills while working in a supportive and patient focused environment.

Apply today!

Why join White Rock Medical Center?

Competitive salary and benefits

Employee programs and events.

Paid Time Off,  5 Company Holidays and 2 Floating Holidays.

Employer paid life insurance.

Additional voluntary benefits such as STD, LTD, etc.

Job Summary

The  Clinical Appeal Specialist  is responsible for reviewing medical records, analyzing insurance denials, and preparing clear, evidence-based clinical and administrative appeals to support appropriate reimbursement for hospital services. This position evaluates clinical documentation, medical necessity, level of care, payer policies, and applicable regulatory requirements to develop persuasive appeal letters for denied inpatient, outpatient, and observation claims.

The Clinical Appeal Writer collaborates with Case Management, Utilization Review, Health Information Management (HIM), Medical Coding, and Revenue Cycle teams to identify supporting evidence, meet appeal deadlines, reduce preventable denials, and improve reimbursement outcomes.

Essential Functions

• Review electronic medical records, physician documentation, diagnostic results, treatment plans, and other clinical records to support medical necessity and level-of-care appeals.
• Analyze claim denials and identify the reasons for adverse payer determinations.
• Research payer policies, contractual requirements, Medicare and Medicaid guidelines, and applicable regulatory standards.
• Prepare accurate, well-organized, and persuasive appeal letters for commercial insurance, Medicare, Medicaid, and other applicable payers.
• Incorporate relevant clinical evidence, treatment timelines, physician findings, and applicable clinical criteria into appeal narratives.
• Collaborate with Case Management, Utilization Review, HIM, Medical Coding, Revenue Cycle, and other departments to obtain supporting documentation and clarify discrepancies.
• Track appeal submissions, payer correspondence, response deadlines, and appeal outcomes to ensure timely follow-up.
• Maintain accurate records of appeal activity, denial trends, and reimbursement outcomes.
• Assist with escalated appeals and prepare supporting documentation for external reviews, administrative hearings, or higher-level appeal processes as needed.
• Identify recurring denial patterns and recommend opportunities to improve documentation, processes, and denial prevention.
• Maintain confidentiality of protected health information and comply with applicable HIPAA requirements, organizational policies, and regulatory standards.
• Perform other duties as assigned.

Behavioral Standards

• Treats everyone as their customer; utilizes scripting and other tools to ensure consistency in customer service; Expresses recognition and shows appreciation to others; fully utilizes AIDET principles; responds quickly to handle requests, complaints, and questions; displays a positive attitude. 

Communication/Knowledge:

• Wears name tag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.
• Excellent communication skills both written and verbal. 

Collaboration/Teamwork

• Attends staff meetings; follows HIPAA guidelines; follows patient rights policy; complies with the compliance program; demonstrates knowledge of role in a disaster; demonstrates knowledge of fire and fire drill procedures; working knowledge of hospital emergency codes; always utilizes standard precautions in the clinical setting; safely manages the environment of care by demonstrating a working knowledge of the requirements of the: Life Safety program, Utilities Management program, Hazardous Materials program, Emergency Preparedness program, Safety Management program, Medical Equipment Management program, Security Management program. 

Requirements

Experience:

• Minimum of 2 years of experience in healthcare, preferably in clinical appeals, utilization review, denial management, case management, medical coding, or hospital revenue cycle.
• Experience reviewing medical records and interpreting clinical documentation preferred.
• Previous experience writing medical necessity appeals or responding to insurance denials strongly preferred.
• Experience with inpatient, outpatient, and observation claims desirable.

Education

• Associate's or bachelor's degree in Nursing, Health Information Management, Healthcare Administration, or a related field preferred.
• An equivalent combination of relevant clinical, coding, utilization review, or healthcare revenue cycle experience may be considered.