Appeals Specialist

Responsibilities:

• Review assigned denials and EOB’s for appeal filing information. Gather any missing information.
• Review case history, payer history, and state requirements to determine appeal strategy.
• Obtain patient and/or physician consent and medical records when required by the insurance plan or state.
• Gather and fill out all special appeal or review forms.
• Create appeal letters, attach the materials referenced in the letter, and mail them.
• Coordinate phone hearings with the insurance company, patient, and physician.
• Comply with all 1^st, 2^nd, 3^rd, and External Level Appeal process, system, and documentation SOP’s.
• Meet appeal filing deadlines by completing assigned worklist tasks in a timely matter and/or reporting to management when assistance is needed to complete the tasks.
• Report all insurance company or state requirements and denial trend changes to the Team Leader and Reimbursement Manager.
• Participate in team and appeal meetings by sharing the details of cases worked.
• Act as a backup on answering incoming telephone calls as needed.
• May undertake special projects assigned by the Team Leader or Reimbursement Manager.
• Ability to meet predetermined Productivity Goals based on the level of Appeal.
• Ability to meet Quality Standard in place (90% or greater).
• Other duties as assigned.

Qualifications:

• High School diploma or GED
• Minimum of four years health insurance billing experience
• Knowledge of managed care industry including payer structures, administrative rules, and government payers
• Proficient in all aspects of reimbursement
• Ability to maintain confidentiality
• Detail oriented
• Possess excellent written and verbal communication skills
• Able to establish priorities, work independently, and proceed with objectives without supervision.
• Proficient in using Microsoft Excel and Word

Originally posted on Himalayas