Payer Audit and Appeal Specialist

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The Payer Audit and Appeal Specialist is responsible to complete the daily activities including all medical document request, and appeals for denied Medicare and Humana Medicare claims related to evidence of medical necessity. The Payer Audit and Appeal Specialist also responds to all payer audits and ensures the timely and accurate submission, inclusive of requested attachments, cover letters, and document annotations providing evidence of compliance with the payer rules. When processing document or audit responses, the Payer Audit and Appeal Specialist evaluates and documents their evaluation against the payer’s requirements in Brightree to ensure accurate reporting and tracking of all activities performed. The Payer Audit and Appeal Specialist works with the leadership team to prepare reports and may assist with conducting analysis for the identification and resolution of trending of patterned denials and overall continued process improvement for management.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Include the following as well as other duties and responsibilities, which may be assigned:

Gathers and submits required documentation, forms, etc. through the established appeals process within a timely manner.

• Conducts follow up activity related to audit and appeal submissions to ensure timely responses and outcomes.
• Accurately identify the denial reasons and request documents needed to appeal the claims through concise, detailed and accurate task requests.
• Responds to all third party payer audits
• Document all efforts involved in audits or requests for documents based on established SOP’s.
• Collaborates with the HPS team to obtain supporting medical records.
• Reviews and analyzes documentation for compliance with payer requirements
• Maintains a strong working knowledge of the Medicare’s appeals process and LCDs, stays up to date on all Medicare LCD changes and communicates updates and changes proactively.
• Adheres to established productivity and quality thresholds
• Provides recommendations for continued improvement to the audit and appeals process
• Adhere to departmental and company policies and procedures

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily and must possess the ability to: interact professionally and ethically with third parties including insurance plans, patients, and caregivers as well as with co-workers and management; handle multiple tasks simultaneously; Provide clear, concise oral and written directives/communications; Quickly assess situations and respond appropriately; Handle special requests in a sensitive, professional manner. Demonstrates the ability to problem solve, prioritize and organize. Ability to follow directives with accuracy and precision; Ability to generate or use different sets of rules for combining or grouping data in different ways; Ability to identify or detect a known pattern that is hidden; Assist with and participate in fostering a team environment.

The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND/OR EXPERIENCE:

• High School Diploma and equivalent work experience.
• Analytical skills required, with strong attention to detail,highly organized
• Excellent verbal and communication skills required
• Ability to work well in a team environment
• Detail oriented individual with 3-5 years of DMEPOS Medicare Medical billing experience or a combination of work experience and education.
• Experience & knowledge of Brightree billing software preferred.
• Proficiency with Microsoft Office including Excel.

TRAINING:

Our industry is a highly regulated industry, and because of that and our commitment to providing the best in class products, services, and support, we require ALL employees to complete the following training programs prior to acting on behalf of the organization to bill or collect products, services, and support systems which we supply:

A. Fraud, Abuse, and Waste Training

B. HIPAA Training

C. Sales Training

D. Systems Training