Claims Appeals Specialist

2 weeks ago


Appleton, Wisconsin, United States Lucent Health Solutions LLC Full time
Job Title: Claims Appeals Specialist

Job Summary:

The Claims Appeals Specialist is responsible for reviewing, analyzing, and processing claims for pre-services and post-service grievances and appeals requests from various customer types and multiple products. This role requires a thorough understanding of coding structures, claims pricing, and COB payments.

Key Responsibilities:

  • Reviews and analyzes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements.
  • Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records.
  • Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents.
  • Maintains and develops workflows with comprehensive notes to enable accurate claims processing related to appeals and refunds.

Requirements:

  • Previous claim processing experience is required.
  • Thorough knowledge of coding structures (CPT, HCPCS, Revenue codes, ICD 9/10 etc.) and COB payments.
  • Ability to understand all types of claims pricing (Network, Medicare, UCR etc.).

Equal Employment Opportunity Policy Statement:

Llucent Health Solutions LLC is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, color, creed, religion, alienage or national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity, gender expression, transgender status, sexual orientation, marital status, military service and veteran status.



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