Appeals Specialist

Job Title: Appeals Specialist

Reports to: Appeals Supervisor

Employment Status: Full-Time

FLSA Status: Non-Exempt
- Job Summary:_

The Appeals Specialist is responsible for all duties related to managing payor contracts, negotiation, and renegotiation of new and existing payor contracts. This position will be responsible for resolution of assigned cases, accurate and timely documentation of case actions, and assist in the oversight of delegates responsible for appeals and grievances functions. This position ensures contracts are appropriately identified, negotiated, implemented, audited, and renegotiated in a timely manner. This position requires prior knowledge of Managed Care in a Provider or Payor setting in addition to understanding of Payer Contracting tasks and activities in the substance abuse and behavioral health field.
- Duties/Responsibilities:_

1. Negotiates payment terms and rates for new and existing contracts that are favorable for the organization efficiently and effectively.

2. Reviews contract terms and conditions to facilitate accurate implementation of contracts proficiently.

3. Manages all payers and markets or assigned geographic area.

4. Monitors renewals of contracts as assigned and renegotiates contract rates and terms as appropriate upon renewal.

5. Establishes productive professional relationships with Payor Negotiators or Representatives.

6. Resolves escalated contract specific issues of Payors.

7. Manages special projects as required.

8. Assists with analysis of payor mix and rate structure of Payor contracts.

9. Identifies, researches, understands and presents Payor contract issues that impact organizations revenue and engage other leadership as appropriate.

10. Maintains a working knowledge of billing database for reporting purposes.

11. All other duties as assigned.
- Required Skills/Abilities:_

1. Ability to proficiently manage multiple tasks simultaneously.

2. Proficiency in the development, coordination, and analysis of payor contracts.

3. Ability to meet sensitive deadlines and organize workload with limited supervision.

4. Must be flexible and work collaboratively with other functional areas of organization to ensure payor contracts are negotiated and structured in a manner that yields a positive impact for the company.

5. Excellent organizational abilities as well as written and oral communications skills.

6. Creative and proficient problem solver.
- Education and Experience:_

1. High School Diploma or equivalent required.

2. 3 years of experience in health plan operations setting preferred, preferably in Appeals & Grievances, Provider Disputes, Claims, Managed Care or Health Care Customer Service.

3. Knowledge in Behavioral Health related medical record guidelines. Relevant experience can include behavioral health treatment center counselor or other positions dealing with behavioral health medical record guidelines.