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Appeals Specialist
Location
United States
Posted
13 days ago
Salary
$22 - $33 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
Appeals Specialist
Intermountain Health
Role Description The RCO Appeals Specialist is responsible for researching and appealing denied medical claims. Responsible to proactively identify insurance denial trends and to then work with Payer Contracting on these issues. Essential Functions: - Understands and uses various contracts and laws (i.e., ERISA, self-funded, State and Federal insurance) to appropriately appeal medical claims that have been denied. - Conducts and refers patient accounts when requested by payers, audit firms, patient and RCO departments to determine the appropriateness of billed charges, chargemaster data, revenue cycle data and UB/HCFA1500 information that is on the claim. - Interprets and accurately identifies the true reason of the denial and reviews payer contracts, clinical data and other data to be able to appeal in a correct and concise way. - Assesses the appropriateness of clinical appeal requests by working with and using evidence-based utilization review criteria, payer policies and Federal and State regulations. - Refers appeal cases to the designated Physician Advisor and works with them to obtain support for appeals. - Collaborates with Care Management, Physician Advisors, Revenue Integrity, Compliance, legal counsel, and RSC teams to prepare appeals. - Identifies trends and opportunities for denial prevention and collaborates with the appropriate multidisciplinary teams to improve denial management, documentation, and appeals process. - Supports legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process. - Serves as a subject matter expert, resource and mentor to others within the RCO, clinical departments, Appeal RN’s, legal, IPAS and Payor Contracting on the art of appealing. Qualifications - Demonstrated experience in a healthcare revenue cycle role. - Demonstrated proficiency in computer skills including Microsoft Office, internet and email. - Demonstrated experience in a role utilizing exceptional written communication skills. - Demonstrates knowledge of State/Federal/ERISA and self-funded insurance laws. - Preferred: Demonstrated experience in healthcare insurance billing, follow-up, denials and appeals or audit role. - Preferred: Bachelor’s degree. - Preferred: Experience with Epic. Requirements - Ongoing need for employee to see and read information, documents, monitors, identify equipment and supplies, and be able to assess customer needs. - Frequent interactions with providers, colleagues, customers, patients/clients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately. - Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy, including frequent computer use for typing and accessing needed information. - May have the same physical requirements as those of clinical or patient care jobs, when the leader takes clinical shifts. - For roles requiring driving: Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles. Benefits - Generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
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