Appeals Specialist I

Primary Job Purpose:

Responsible for all activities associated with requests for Provider Billing Disputes and Appeals. Includes analysis, preparation, evaluation of prior determinations, coordination of clinical review if needed, decision making, notification, and completion. Follows guidelines outlined by subscriber or provider contracts, company documents, government mandates, other appeals regulatory requirements and internal policies and procedures. Provides information and assistance to members, providers, other insurance companies, and attorneys or others regarding benefits and claims. Does not make final clinical decisions but has access to licensed health professionals who conduct clinical reviews for appeals.

Normally to be proficient in the competencies listed below:

Appeals Specialist I would have a high school diploma or GED and a minimum 4 years' experience in Regence Customer Service, Claims, or Clinical Services or equivalent combination of education and work experience.

Responsibilities:

Responsible for all activities associated with appeal analysis, decision-making and closure as described below:

• Appeal Intake - Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal. Document information in appropriate system.

• Appeal Analysis - Review claim coding and claim processing history, medical policy and reimbursement policies, regulatory and legal requirements, benefit contracts, and/or provider contracts. Collect and catalogue supporting documentation and formulate an appeal recommendation. Document information in appropriate system. Apply knowledge and experience to answer a variety of increasingly complex inquiries from members, providers, and provider representatives. Collaborate effectively with coding specialists, appeal nurses, physician reviewers, and others as necessary to reach timely decisions on appeals.

• Decision & Closure - Make non-clinical appeal determinations as permitted by department business processes and guidelines. Follow department's processes to receive a clinical review and decision from licensed health professionals. Present complex cases to appeal panels, document decisions, communicate determinations to members, providers or their representatives. Document information in appropriate system(s).

• External review process - Oversee set-up of appeals for external review organizations, including document collection and coordination, communication with all parties, and other responsibilities as an intermediary between the provider and the external review organization. Ensure external review information is documented in appropriate system. Prepares letters and cases for external review as needed. Implement external review decisions.

• Interpersonal and Communication - Provide information, education and assistance to members, providers, and their representatives. Facilitate the member's or provider's' understanding of the appeal process and of the information necessary to effectively process an appeal. Be a courteous advocate to the member or provider when requesting supporting information. Work cooperatively and effectively across all business areas to resolve.

• Systems and data - Track appeals in appropriate systems and assist in the maintenance of files. Assist with compilation of reports on appeals, including trends, number of cases, decisions, suggestions for process improvement, types of appeals, and compliance with timelines.

• Support, apply and promote Provider or Member Appeal Policies & Procedures.

• Adhere to dependability, customer focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all work.

• Manage a defined caseload within department productivity and quality expectations and provide back up for other appeals staff.

• May perform as expert witness during any level of appeal, regarding policies, procedures and member or provider appeal rights.

• Meet timeliness standards as set forth through department policies and procedures, subscriber summary plan descriptions, performance guarantees, and regulations.

Minimum Requirements:

• Excellent verbal and written communication skills.

• Intermediate computer skills (e.g. Microsoft Word, Excel, Outlook) and experience with Regence systems.

• Knowledge of medical terminology, anatomy and coding (CPT, DX, HCPCs).

• Knowledge of Regence claims processing and clinical services operations.

• Demonstrated initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing a course of action.

• Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all aspects of internal and external contacts.

• Ability to present complex medical and reimbursement information to others and to be diplomatic and persuasive regarding health plan benefits, claims and eligibility.

• Ability to switch from one task or type of work to another as the business needs require.

• Ability to effectively prioritize work to meet strict timelines while maintaining quality and consumer centric focus.

Required Licenses, Certifications, Registration, Etc.:

Coding Certification preferred for Specialist I and II.

Work Environment:

• Travel may be required, locally or out of state.

• May be required to work overtime.