Responsibilities:
- Review assigned denials and EOB’s for appeal filing information. Gather any missing information.
- Review case history, payer history, and state requirements to determine appeal strategy.
- Obtain patient and/or physician consent and medical records when required by the insurance plan or state.
- Gather and fill out all special appeal or review forms.
- Create appeal letters, attach the materials referenced in the letter, and mail them.
- Coordinate phone hearings with the insurance company, patient, and physician.
- Comply with all 1st, 2nd, 3rd, and External Level Appeal process, system, and documentation SOP’s.
- Meet appeal filing deadlines by completing assigned worklist tasks in a timely matter and/or reporting to management when assistance is needed to complete the tasks.
- Report all insurance company or state requirements and denial trend changes to the Team Leader and Reimbursement Manager.
- Participate in team and appeal meetings by sharing the details of cases worked.
- Act as a backup on answering incoming telephone calls as needed.
- May undertake special projects assigned by the Team Leader or Reimbursement Manager.
- Ability to meet predetermined Productivity Goals based on the level of Appeal.
- Ability to meet Quality Standard in place (90% or greater).
- Other duties as assigned.
Qualifications:
- High School diploma or GED
- Minimum of four years health insurance billing experience
- Knowledge of managed care industry including payer structures, administrative rules, and government payers
- Proficient in all aspects of reimbursement
- Ability to maintain confidentiality
- Detail oriented
- Possess excellent written and verbal communication skills
- Able to establish priorities, work independently, and proceed with objectives without supervision.
- Proficient in using Microsoft Excel and Word