Medical Appeals Representative

About the Role

This full-time position is within the Enterprise Revenue Cycle - Enrollment Department, Southeast region, at Advocate Health, operating remotely with a standard Monday to Friday first shift schedule. The role primarily involves managing medical appeals related to Medicaid denied accounts by reviewing medical records, analyzing patient conditions against disability criteria, and preparing appeals documentation.

Responsibilities

• Request and review medical records to evaluate patient eligibility based on disability listings.
• Assess and decide whether to initiate appeals or accept denials, supporting Financial Counselors with cases needing detailed medical reviews.
• Compose detailed written arguments for presentation to Income Maintenance Caseworkers and during local and state hearings, including preparation of witnesses.
• Interpret legal aspects related to specific denial circumstances and actively participate in hearings by delivering oral and written arguments and responding to written summaries by county officials.

Work Environment and Physical Requirements

The position requires working in patient rooms or dynamic office settings with frequent interruptions. Some travel is necessary to represent patients during appeals. Collaboration with attorneys or paralegals is key for complex eligibility issues.

Qualifications

• Minimum requirement: High School Diploma or GED; Bachelor's Degree is preferred.
• At least 5 years of experience in financial counseling, Department of Social Services, or medical appeals is required.
• Experience with appeals and state hearing processes is advantageous.

Compensation and Benefits

• Salary range: $25.30 to $37.95 per hour, dependent on qualifications, experience, and skills.
• Additional compensation such as shift differentials and incentive pay may apply based on the role.
• Comprehensive benefits include paid time off, medical, dental, vision, life insurance, short- and long-term disability, flexible spending accounts, adoption assistance, paid parental leave, retirement plans with employer matching, and educational assistance programs.

Additional Information

Candidates must reside within the states of AL, CO, FL, GA, ID, KS, KY, ME, MI, NC, SC, VA, VT, or WA. Eligibility for benefits and programs depends on employment status (e.g., full-time or part-time). Advocate Health is a leading nonprofit integrated health system providing advanced care, clinical innovation, and community benefits across multiple states.