(Not a remote position) The Appeals Specialist is responsible for validating employee outputs in various areas including; Claims, Member / Provider Service, Enrollment and regulatory compliance. The Appeals Specialist collaborates with business partners across Operations and external vendors to create and maintain quality policies and processes to assure appeal meets the agreed standards. Sets up and maintains case files for each grievance and collects the information required by organizational policies and applicable regulations. Appeal Resolution Specialist conducts research and coordination needed to evaluate, process, respond to, and refer or close appeals.

Key Functions / Responsibilities:

• Evaluates department outputs for accuracy and compliance with processing guidelines and efficiency.
• Conducts research, compiles, and analyzes denials to identify the root cause of problems and recommend process improvements.
• Conduct accurate and timely appeal review of claim adjudication activities including adjudication policies and procedures and guidelines.
• Executes the appeal process by providing supporting documentation and determinations and / or audit finding.
• Tracks daily evaluation completion of assigned processing task / function an provides any noticeable performance trend data to appropriate management team.
• Coaches and provides ongoing feedback to staff based on trends.
• Assists with calibration sessions in accordance with department standards, to help ensure consistency and validation of audit parameters, and requirements.
• Provides suggestions on new process documentation and materials to support quality initiatives and to improve overall performance and compliance across the teams.
• Provides feedback to department team leaders and managers.
• Identifies and documents defects, inconsistences and potential risk in workflow process and documentation.
• Maintains a comprehensive understanding of appropriate departmental policies procedures and audit specification.

Required Experience:

• Minimum of 1 year of experience in Revenue Cycle and Auditing.
• 1 - 3 years exposure in various departments in a health insurance organization such as; customer service, and/or enrollment, claims and premium billing expedience or equivalent experience is required.

Preferred / Desirable:

• Previous health insurance work experience.
• 2 or more years appeals experience.
• Physical Therapy knowledge is a plus.
• Neuropathy pain management, and Physical Therapy Billing experience

Competencies, Skills, and Attributes:

• Strong interpersonal communication and relational skills.
• Detail Oriented person, with understanding of CPT, HPCS, and ICD-10 coding.
• Must be able to work collaboratively and cooperatively as a team member.
• Ability to synthesize and process complex information and deliver the information both verbally and in writing in a clear, concise and articulate manner.
• Highly organized, detail oriented and self-directed with the ability to work independently and in team setting.
• Excellent analytical, oral, verbal, and written communication skills and customer service skills.
• Must be able to multi-task, prioritize projects and work well with deadlines.
• Must be flexible and willing to perform all necessary and appropriate duties to ensure the attainment of departmental and organizational goals.
• Ability to review medical records to justify coding before appealing denied services.
• Ability to work independently, but closely with team lead.
• Working knowledge and basic understanding in Claims, Enrollment and Member / Provider, and procedures is required.
• Knowledge of Insurance guidelines, MCR guidelines and LCD policies is a must.
• Insurance websites experience is a must.

• Must be organized, and able to follow up on appeals that have been submitted.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Ability to work voluntary overtime during peak seasons.
• Requires the ability to balance multiple priorities and function in a complex, rapidly changing environment.

Job Type: Full-time

Pay: $15.00 - $22.00 per hour

Benefits:

• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Education:

• High school or equivalent (Preferred)

Experience:

• Medical Billing and/or Coding: 1 year (Required)
• Medical Appeals: 2 years (Preferred)

Work Location: One location

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