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