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Healthcare Appeals Specialist
2 months ago
- Review providers' requests for services and coordinate appeals management review.
- Generate appeal letters to substantiate medical necessity and out-of-network underpaid claims.
- Prepare appeal letters for IDRE for denied and underpaid claims.
- Monitor denials and financial metrics associated with the front-end review process.
- Collect data, prepare analysis, and oversee communication tools for governmental and non-governmental agencies.
- Review cases received from Patient Access to verify insurance pre-certification/notification process completion.
- Manage/follow-up on appeal status with Managed Care Payors or regulatory agencies.
- Notify Department Leadership of potential missed timeframes for submission and follow-up on responses.
- Serve as a liaison between patient account services, physicians, and develop/validate daily work lists for Appeals Manager.
- Assist with insurance and regulatory audits and provide information to Manager related to inaccurate and/or missing documentation.
- Provide support for ongoing projects as required.
- Knowledge of CPT and ICD 10 coding with excellent written skills.
- Coding Certification preferred.
- Minimum of 3 years Healthcare experience.
- Sound knowledge and skill in the use of personal computer and software for word processing, spreadsheet, and database applications.
- Ability to effectively communicate with all levels of hospital staff in a verbal and written manner.
- Demonstrated ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
- Courteous and professional demeanor, team spirit, and ability to work in a collaborative, effective manner.
- Ability to utilize critical thinking and apply sound clinical judgment and assessment skills for decision-making.
