Payer Specialist

Overview

Respond to all assigned levels of denials by directly contacting payers to verbally challenge claim denials and request re-processing. Ensures payers are following medical policy as agreed upon in contracts with client.  Submitting additional information to support processing of claims to include appropriate medical records, and appeal letters to insurance companies within the appeal filing time limits. Act as a client representative by identifying the path needed to obtain the maximum reimbursement under the insurance plan to get the denial overturned.

Responsibilities

• Review patient medical record and payer medical policies to determine validity of denials.
• Execute phone calls to payers to challenge denials and request re-processing where denials are invalid.
• Submission of and follow-up on payer reconsideration requests; providing additional challenges to payers.
• Recognize and report payer trends to Management and Client.
• Create detailed spreadsheets as requested by Management.
• Complete payer projects as requested by Client or Management.
• Research payer medical policies and insurance plan types to insure up-to-date information is on file.
• Review assigned denials and EOBs for appeal filing information. Gather any missing information.
• Review case history, payer history, and state requirements to determine verbal challenge and appeal strategy.
• Gather and fill out all special appeal or review forms.
• Create appeal letters, attach the materials referenced in the letter, and mail them.
• Comply with Appeal or Insurance processes, system, and documentation SOPs.
• Participate in team and appeal meetings by sharing the details of cases worked.
• Act as a backup on additional production based work lists, as needed.
• Ability to meet predetermined Productivity Goals
• 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
• Possess excellent written and verbal communication skills
• Well-developed problem-solving/analytical skills
• Experience utilizing Payer Web Portals
• Experience reviewing medical records and knowledge of medical terms
• Proficient with PAS and HARP systems
• 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
• Able to establish priorities, work independently, and proceed with objectives without supervision.
• Proficient in using Microsoft Word and Excel