Appeals Specialist I

Job Description

Patient primary insurance claims denied reimbursement by a DMERC will be evaluated and processed in a timely manner in accordance with State and Federal laws. Patient primary insurance claims denied reimbursement by Medicare may be processed through the Redetermination, Reconsideration, and Administrative Law Judge levels of Appeal.  Reviews all Medicare denials and initiates the next appeal step for Reconsideration or ALJ Hearing process with the appropriate DMERC consistent with the requirements specified by Medicare Appeal Process outlined in the DMERC Provider Manual.


Provide lead with work progress reports on a daily, weekly, monthly basis or as required Investigate and analyze patient charts and wound progress reports, by reading documents and negotiating computer-based research To develop, for each Medicare Insurance claim denial, a reasonable patient product use detail and history; to develop and substantiate the product use evidence, and present the patient’s case to Medicare in the manner required or make appropriate adjustments Write a medically concise and issue focused Redetermination, Reconsideration, or Administrative Law Judge letter as required as it applies to Medicare policy Pull patient denials and/or partially paid claims in appropriate numbers in order to maintain timely completion of the Appeals Department filing limit caseload Review Medicare required documentation needed for appeal of denial and/or partial denial of payment. (i.e. Number of wounds, new wound(s), re-start patient, wound improvement, billing cycle number of denied or partially denied claim.) If documentation is missing from the patient’s chart, print documents from Alchemy and/or FileNet Generate a chronological outline (supply worksheet) of the patient’s VAC rentals and supply purchases showing payments and denials to substantiate reason for Medicare payment reconsideration Consistently meet and maintain production and quality levels as established by management Understand their role and impact they have in the departmental team; including exhibiting positive attitudes, willingness to help wherever asked, staying focused and on task to the matter at hand, and being part of the success of your team Read and reply to e-mail in a timely manner as needed Performs other duties as assigned


  • High School diploma or equivalent
  • One year relevant work/educational experience
  • Ability to recognize the need for escalation
  • Proficient PC skills
  • Demonstrates excellent problem-solving skills
  • Working 10-key and/or keyboarding skills
  • Proficiency in general office duties
  • Ability to prioritize
  • Attention to detail
  • Ability to enter date accurately
  • Demonstrate good interpersonal skills
  • Ability to maintain complete confidentiality and discretion in business relationships
  • Demonstrate willingness and ability to participate in, and complete, all required training programs
  • Ability to work effectively and exercise sound business judgment in a team environment, as well as independently
  • Demonstrate flexibility in work shift to meet department needs
  • Demonstrate ability to deal effectively with all employees and external business contacts while conveying a positive service-oriented attitude
  • Perform duties in an organized, accurate and complete manner evaluated and validated via quality assurance assessment
  • Ability to communicate effectively, both verbally and in writing, with all levels of external and internal customers
  • Ability to work under pressure and meet deadlines
  • Ability to work at computer and maintain constant keyboarding


  • Microsoft Word - proficient
  • Microsoft Excel - fundamental
  • Microsoft Outlook - fundamental
  • File Management - proficient
  • FileNet - fundamental (external hires to be trained)
  • MicroMD, Medical Manager, Delair – fundamental (external hires to be trained)
  • Alchemy – fundamental (external hires to be trained)
  • Hero – fundamental (external hires to be trained)
  • VAC Recertification Program – fundamental (external hires to be trained)
  • 6 months proven above average work performance at KCI
  • Goal oriented
  • Task oriented
  • Knowledge of Insurance Appeals Process
  • Understanding of wound etiology


This position reports to department 1)lead, 2)supervisor and 3)manager.

This position supervises/manages no other employee.


Working conditions are typical of a general office environment.  May require long periods of sitting or standing and consistent keyboarding.  Overtime may be required as deemed necessary by business objectives.

The information listed above is not a comprehensive list of all duties/responsibilities performed. This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice. Any physical and mental requirements described in this job description are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. EOE AA M/F/Vet/Disability: Acelity L.P. Inc. and its subsidiaries are an equal opportunity and affirmative action employer and give consideration for employment to qualified applicants without regard to race, ethnicity, color, religion, sex, sexual orientation, gender identity, pregnancy, national origin, age, disability, veteran status, or genetic information or any other legally protected characteristic. If you'd like more information about your EEO rights as an applicant under the law, please click here: VEVRAA Federal Contractor