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SGS-Appeals Specialist

3 months ago

Bethesda, United States Cynet Systems Full time

Description:
Job Summary
The Claims Specialist-Appeals assesses and facilitates ongoing support for *** Government Solutions (SGS) Claims Operations. Responsibilities include assessing and handling appeals; serves as the subject matter expert for claims appeals; and to serve as the liaison between claims operation and the client.
Job Description
Essential Functions
Duties and Responsibilities
Gathers and reviews claim appeal documentation including, but not limited to, appeal request letters, and medical documentation.
Reviews medical documentation and provides claim expertise on appealed claims.
Prepares appropriate claim Form to client summarizing the appeal review determination.
Adheres to the highest quality and ethical standards when reviewing appealed claims and making determinations.
Ensures integrity of the claim appeal process and ensures compliance with the Client's requirements.
Monitors and tracks the number of appealed claims.
May perform other duties, as needed, to meet the needs of the business.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee frequently is required to use the fingers to make small movements such as typing, picking up small objects, or pinching fingers together. The employee is occasionally required to walk; reach with hands and arms; stoop, kneel, crouch, or crawl. Sedentary work. Sitting most of the time. Specific vision abilities required by this job include close vision, peripheral vision, depth perception, and the ability to adjust focus.
The employee moves within the facility in which their office is located to access file cabinets, documents, office machinery, and other equipment. They also travel within their home office or facility in which their office is located and to locations outside of the facility, to attend meetings, training, events, and other business activities. An employee in this position may lift, carry, push, and/or pull objects weighing up to 10 lbs.
The employee holding this position must have strong communication and organizational skills, and an ability to interact and work with others. They must be able to work under time constraints and deadlines.

Requirements:
Its a remote role.
3 months project. Possible temp to hire
Job Specifications
Education
High School Diploma or GED required
Preferred bachelor's degree in healthcare, medical bill review (claims) processing or a related field, education may be substituted with experience including four or more years of experience in medical bill review (claims) processing.
Preferred Medical Billing and Coding Certification- CPC-Certified Professional Coder, CBCS- Certified Billing and Coding Specialist, CCS-Certified Coding Specialist, or CPC-Certified Professional Coder.
Experience
4 years of experience in medical billing or, processing
Medical coding experience, is a plus
General Medical record knowledge and requirements
Familiarity with federal fee schedule, Medicare, Medicaid, Tricare, Veterans Administration or any federal fee schedule bill review experience is a plus
Excellent oral and written communication skills
Excellent presentation skills
PC literate, including Microsoft Office products as well as MS Teams
Strong organizational skills
Excellent interpersonal and negotiation skills
Travel as required
Ability to work independently and in a team environment.
Ability to work remotely.
Communication Skills
Excellent organizational and project management skills. Superior customer service skills working proactively and collaboratively with stakeholders to implement and enhance internal and external information for management. Demonstrated ability to communicate, present and influence credibly and effectively at all levels of the organization
Strong English language skills, including but not limited to speaking, writing, spelling, and grammatical skills. Must write succinctly and clearly and explain complex situations in plain English to technical and non-technical audiences.
Reasoning Ability
Ability to apply logical or scientific thinking to a wide range of intellectual and practical problems. Able to deal with very difficult concepts and complex variables. Ability to comprehend, analyze, and interpret documents. Ability to solve problems involving several options in situations. Requires intermediate analytical and quantitative skills.
Scope of Responsibility
Decisions are made with the understanding of procedures and company policies to achieve set results and deadlines. Responsible for setting team project deadlines. Errors in judgment may cause a long-term impact on the client, team, and company
Other Skills and Abilities, Qualifications
Embraces change; maintains an open mind and is flexible and adaptable in the face of ambiguity and change.
Ability to work independently, multitask, and adjust priorities.
Strong communication skills (verbal and written)
Ability to work in a team environment to build and communicate a business case and plan.
Intermediate to advanced knowledge of Microsoft Office Suite (Word, Excel, Access, Outlook, PowerPoint) and Authoring tools
Work on complex issues where analysis of situations or data requires an in-depth evaluation of variable factors.
Exercises judgment and discretion in selecting methods, techniques, and evaluation criteria.
Exceptional analytical and problem resolution skills; ability to exercise independent, sound judgment.
Proactively seeks opportunities to increase knowledge, skills, and abilities.
Takes ownership of personal actions and outcomes; encourages and empowers others to do the same.
United States Citizenship
Must be able to obtain and maintain confidential-level security clearance(s) as required.