Appeals Specialist Full Time

Position Goal: Responsible for monitoring contractual allowances, analyzing and pursuing appeal opportunities with payers and networks, and reporting appeals performance.

Position Responsibilities:

Implements process for identifying under-allowed claims using Experian Contract Manager and other available tools.

Reviews and analyzes EOBs for identified under-allowed claims.

Verifies applicable contract by, as dictated by operational procedures: reviewing EOB messages, reviewing patient ID card, verifying member information for managed care plans.

Uses feedback and experience to refine communication skills and tools for use in preparing written and telephone appeals.

Batches appeals, when applicable, by payer or network, by CPT/HCPCS code combination, by error type, or by provider.

Compiles and submits appeals and monitors for proper reimbursement.

Uses Experian Contract Manager to track appeals and recoveries.

Establishes and cultivates helpful and effective contacts in payer or network offices.

Establishes follow-up protocol with payers and networks.

Monitors and tracks contractual, billing, registration, and posting errors, and provides continuous feedback to the Director of Revenue Optimization Management

Participates in meetings to discuss ongoing trends and issues regarding the administration of managed care contracts.

Cross-trains and performs appeals analysis within Hospital claims, as needed.

Maintains the strict confidentiality required for medical records and other data.

Participates in professional development efforts to ensure currency in managed care reimbursement trends.

Experience: Five years with insurance claims/related experience, CPT and ICD-10 terminology experience required or three years of above described experience with a Associates degree or higher in related field

Education: High school diploma or equivalent required. Associates degree or higher preferred.

Special Qualifications (required):

Knowledge and PC skills, with proficiency in utilizing Microsoft office products (Word, Excel, Outlook, PowerPoint, etc.)

Knowledge of medical terminology.

Demonstrated skill in written and oral communication with colleagues, supervisors, and payer/network personnel.

Demonstrated skill working in a team-oriented structure to achieve goals.

Must be able to work independently.

Special Qualifications (preferred):

Coding certification preferred.

Knowledge of networks, IPAs, MSOs, HMOs, PCP and contract affiliations.

Knowledge of the health care professional services billing (physicians and related health care professionals) and reimbursement environment.

Knowledge of major types of practice management system (PMS) and EOB imaging systems.

Knowledge of managed care contracts and compliance.

Demonstrated skill in gathering and reporting claims information.

The Hughston Clinic, The Hughston Foundation, The Hughston Surgical Center, Hughston Clinic Orthopaedics, Hughston Medical, Hughston Orthopaedics Trauma, Hughston Orthopaedics Southeast and Jack Hughston Memorial Hospital participate in E-Verify. This company is an equal opportunity employer that recruits and hires qualified candidates without regard to race, religion, color, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.