What are the responsibilities and job description for the Clinical Appeals Specialist position at Curitec?
Job Description:
Curitec, a medical insurance company specializing in DME/Supplies, is searching for a highly detail-oriented and self-starting Clinical Appeals Specialist to join our Appeals team in The Woodlands. This role focuses on the clinical review and appeal of denied claims for durable medical equipment, wound care, and specialty supplies, ensuring compliance with Medicare Part B regulations. The ideal candidate has significant clinical knowledge and expert analytical skills, capable of efficiently navigating complex medical documentation and regulatory guidelines daily.
Required Skills and Experience:
Education: Minimum of a two-year degree in a clinical health-related field (e.g., LPN, LVN, Health Information Management, Medical Assisting) or equivalent experience is required.
Minimum of 3 years of recent clinical experience or clinical administrative experience (e.g., Utilization Review, Coding, Medical Records).
Minimum of 2 years of experience specifically in clinical appeals, utilization review (UR), or claims denial management within a managed care or insurance setting.
Expert knowledge of Medicare Part B coverage criteria and regulations, especially pertaining to DMEPOS and wound care.
Proven ability to interpret complex medical records and clinical guidelines to establish medical necessity.
Exceptional written communication skills for composing factual and persuasive appeal arguments.
Strong critical thinking and analytical problem-solving abilities.
Computer literate – Proficiency with Microsoft Outlook and Excel is mandatory.
HIPAA Compliance is mandatory.
Daily Responsibilities:
Conducting clinical reviews of denied claims (all appeal levels) focusing on DME/Wound Care necessity.
Meticulously analyzing clinical records, policy guidelines, and billing data to determine grounds for appeal.
Drafting, preparing, and submitting comprehensive, evidence-based appeal letters to external review bodies (e.g., CMS, ALJ).
Documenting all appeal activity accurately within the case management system.
Communicating appeal outcomes clearly to providers, patients, and internal departments.
Identifying and reporting claim denial trends to management for process improvement.
Staying current on all changes to federal and state coverage guidelines (Medicare Part B).
Job Type: Full-time
Pay: $55,000.00 - $65,000.00 per year
Benefits:
- 401(k)
- Health insurance
- Paid time off
Work Location: In person
Salary : $55,000 - $65,000