Job Summary

The Inpatient Appeals Coordinator at Care New England is responsible for the coordination, preparation, submission, and follow-up of inpatient clinical and administrative appeals to maximize appropriate reimbursement and resolution of denied or underpaid claims. The Inpatient Appeals Coordinator serves as a subject matter resource for inpatient denial and appeal processes and works collaboratively with Revenue Cycle, Coding, CDI, Utilization Management, Case Management, physicians, clinical departments, and payer representatives to identify and resolve issues impacting reimbursement.

The Inpatient Appeals Coordinator reviews inpatient denials and supporting medical record documentation to determine the appropriate appeal strategy and ensure appeals are supported by accurate clinical, coding, and regulatory information. This role researches payer-specific requirements, contractual provisions, medical necessity criteria, and applicable regulatory guidelines to develop clear, comprehensive, and timely appeal submissions.

The Coordinator is responsible for monitoring appeal deadlines and payer response timelines, maintaining accurate documentation of appeal activity, and escalating issues that may impact timely filing, reimbursement, or financial recovery. The role identifies trends in denials and appeals and collaborates with leadership and appropriate stakeholders to address recurring issues, improve processes, and reduce preventable denials.

Duties & Responsibilities

• Adherence to applicable CMS regulations, payer policies and requirements, organizational policies and procedures, and other governing regulatory guidance is required.
• Review and analyze inpatient denials, non-payment, underpayment, and other payer determinations to identify appropriate appeal opportunities.
• Review inpatient medical records, clinical documentation, coding, claims information, and payer correspondence to determine the basis of the denial and appropriate course of action.
• Develop and submit timely, accurate, and well-supported first-level and subsequent-level appeals in accordance with payer-specific requirements.
• Prepare compelling appeal letters that clearly articulate the clinical, coding, regulatory, and/or contractual basis for reimbursement.
• Coordinate with physicians, CDI specialists, inpatient coding, utilization management, case management, clinical departments, and other subject matter experts to obtain supporting documentation and clinical information necessary for appeals.
• Identify cases requiring physician review, clinical validation, coding review, or additional documentation and coordinate appropriate follow-up.
• Monitor appeal submission deadlines, payer response timelines, and escalation requirements to ensure appeals are processed within applicable timeframes.
• Maintain accurate and complete documentation of appeal activity, including denial rationale, appeal submission dates, payer responses, outcomes, and financial impact.
• Track and follow up on outstanding appeals and escalate delayed or unresolved cases as appropriate.
• Collaborate with Revenue Cycle leadership and appropriate operational departments to identify root causes of denials and develop strategies to reduce preventable denials and improve appeal outcomes.
• Maintain working knowledge of inpatient reimbursement methodologies, coding principles, clinical documentation requirements, and payer policies as they relate to denials and appeals.
• Perform other related duties as assigned.

Requirements

• High School or GED Required; Associate's Degree Preferred
• Minimum 3 to 5 Years
• Working knowledge of inpatient hospital reimbursement, claims processing, and payer denial and appeal processes
• Strong understanding of medical necessity, level of care, coding, clinical documentation, and reimbursement concepts applicable to inpatient services
• Knowledge of Medicare, Medicaid, commercial payer, and other applicable payer requirements and appeal processes
• Ability to analyze denial rationale and determine appropriate appeal opportunities and supporting documentation
• Knowledge of payer-specific timely filing requirements, appeal levels, submission requirements, and response timelines
• Strong written communication skills with the ability to develop clear, concise, and well-supported appeal letters
• Effective communication and collaboration skills to work with physicians, CDI, coding, utilization management, case management, revenue integrity, and other revenue cycle departments
• Strong organizational skills and ability to manage multiple appeals, deadlines, and priorities simultaneously
• High attention to detail and commitment to accuracy
• Ability to identify trends, root causes, and opportunities for process improvement related to inpatient denials and appeals
• Ability to maintain confidentiality and handle protected health information in accordance with organizational policies and applicable regulations