Appeals Professional/Dispute Resolution Reviewer/Case Analyst

Healthcare Quality Strategies, Inc. - Appeals Professional/Dispute Resolution Review 1/Case Analyst

FT – Remote Work Environment - Applicants must be based in FL

Reviews documentation requirements and evidence for appeals and/or rebuttals of healthcare claims appeals, enrollment denials, revocation and or suspension. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

Essential Responsibilities:

Reviews medical records/case file, writes a decision that is clear, concise, and impartial and supports the determination made, and documents review.

Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy.

Responds to and ensures that all issues raised by the beneficiary, representative, supplier, and provider

have been addressed.

Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.

Conducts research using online federal regulations, contract policy, standards of medical practice, contract

manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate

and well-supported decision.

Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures.

Participates in special projects and performs other duties as assigned.

Education

AAPC or AHIMA Certification and/or a minimum of Associates Degree or technical/trade school diploma in medical billing or medical coding.

5-10 years of related experience in a healthcare billing environment may be considered as a substitute for formal education or certification requirements.

Experience:

Minimum 3-5 years of healthcare/health plan claims processing, utilization review, medical billing, medical coding necessary

Required Skills and Abilities

Research techniques

Medical terminology

Understanding of healthcare coverage and payment rules

Understanding of healthcare regulations, claims administration, and medical review processes

Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and

reviewing documents for clarity and consistency

Prioritizing and organizing work assignments

Multitask and meet deadlines

Exercise logic and reasoning to define problems, establish facts and draw valid conclusions

Make decisions that support business objectives and goals

Identify and resolve problems or refer issues appropriately

Communicate effectively verbally and in writing

Adapt to the needs of internal and external customers

Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards

Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities

Excel and Word Proficiency a must

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

For immediate consideration, please apply via the HQSI Careers Page at: > Careers > Current Employment Opportunities

EOE: Minorities/Females/Disabled/Veterans

Healthcare Quality Strategies, Inc. is Equal Opportunity, Affirmative Action Employer and an Alcohol/Drug Free Workplace

Healthcare Quality Strategies, Inc. is an E-Verify Employer