Appeals Specialist

Overview

Respond to all assigned levels of denials by submitting appeal letters and required documentation to insurance companies within the appeal filing time limits. Submit external review requests and required documentation to the state within the filing time limits.  Act as a patient advocate by identifying the path needed to obtain the maximum reimbursement under the insurance plan and work with the patient to get the denial overturned.

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 1st, 2nd, 3rd, 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