What are the responsibilities and job description for the Appeals Specialist position at CentraCare?
Full-time 80 hours every 2 weeks | Mon-Fri 8a-430p | Work From Home
JOB SUMMARY:
Responsible for recovering lost reimbursement or at-risk reimbursement as a result of payer audits and denials (full or partial) including but not limited to clinical, medical necessity and payer policy denials through appeal. Reviews unfavorable findings from payers or payer auditors and carries out the appeals process to obtain full contractual reimbursement. The Appeals Specialist also works to prevent future denials by communicating with leadership about denial root causes and helps develop and implement education and process improvements. Works to maintain payer relationships, including responding to inquiries, complaints, and other correspondence. Knowledgeable of state/federal laws that relate to contracts and appeals process. Implements and abides by Customer Services Standards, supports, and implement patient safety practices as appropriate. Supports and demonstrates Family and Patient Centered Care principles, when interacting with patients and their families and with co-workers.
EDUCATION:
- Associate Degree (two year degree) at a minimum
- 3 years experience in a healthcare setting in lieu of education
- 1 years Previous experience constructing successful appeal letters required; experience with clinical appeal letter writing is a plus
- 3 years Previous experience in professional or hospital billing
- Previous office experience and knowledge of Revenue Cycle, Epic, Third Party Payers preferred. Specific experience related to medical terminology, anatomy and physiology, charge documentation, auditing and Payer contracts a plus
- Specific experience related to medical terminology, charge documentation, coding, auditing and Payer contracts a plus
- One year of medical coding experience preferred
- Familiarity with National Coverage Determination and Local Coverage Determination, medical necessity screening criteria (e.g. MCG, InterQual), proficient in medical terminology and able to interpret patient medical records
- Requires advanced knowledge of claims processing system, Electronic Health Record, Microsoft Office applications (particularly Microsoft Excel) and other technology as assigned
- Demonstrates ability to analyze information, plan effective actions and follow through reliably to meet expectations Upon Hire
- Strong problem-solving, interpersonal, analytical, verbal and written communication skills required
Our roots go back to 1886 when St. Cloud Hospital was built to serve the health care needs of people living in Central Minnesota. In 1995, CentraCare was formed, which today includes eight hospitals in St. Cloud, Long Prairie, Melrose, Monticello, Paynesville, Redwood Falls, Sauk Centre and Willmar. We also have more than 30 clinics, 11 senior housing facilities and seven long-term care facilities throughout the area.
CentraCare has grown to meet the needs of the communities and is now one of the largest health systems in Minnesota. This means we are able to offer the latest advancements in care, technology and treatments close to home. But what makes CentraCare special is not our facilities or technology. It is our people. We live in the communities we serve. We are neighbors, friends and family. And when you need us, we are here for you.
