Appeals Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate administrative appeals to confirm their suitability for review and establish the appropriate workflow.

• Direct appeals accordingly when new information necessitates clinical evaluation.

• Handle non-clinical facility appeals related to payment disputes, reimbursement amounts, contract interpretations, and processing errors.

• Examine payment histories and contracts within client applications.

• Manage clinical appeals when no new clinical data is provided.

• Make appeal decisions based on client and/or organizational guidelines.

• Deliver clear, comprehensive, and precise responses to appeals.

• Collaborate and communicate with Clinical Review teams upon receipt of new clinical information or when escalation is needed.

• Inform stakeholders about urgent issues or emerging trends.

⛳️ Requirements

• Associate degree (preferably in healthcare) or a relevant combination of education and experience.

• Minimum of 1 year of experience in healthcare claims, appeals, billing, or revenue cycle.

• Experience in the administrative review of clinical appeals.

• Strong professional judgment and awareness of escalation protocols.

• Capability to analyze case specifics and make prompt, informed decisions.

• Ability to swiftly learn and navigate new systems and platforms.

• Basic knowledge of claims adjudication processes and terminology.

• Exceptional written and verbal communication skills.

• Proficient in managing tasks and prioritizing workload effectively.

• High attention to detail and accuracy in documentation.

• Proficiency in MS Office applications, including Outlook, Excel, and Word.

• Ability to multitask, handle a high-volume caseload, and meet strict time-sensitive deadlines.

• Capacity to work independently.

• Patience and the ability to maintain composure under pressure amidst frequent interruptions.

• High-speed internet (recommended 100 Mbps per person) with secured WIFI.

• Dedicated workspace with minimal distractions to safeguard PHI and HIPAA information.

• Ability to sit and operate a computer keyboard for extended periods.

🏝️ Benefits

• Remote work opportunities.

• Requirement for high-speed internet with secured WIFI.

• Dedicated workspace with minimal interruptions to ensure the protection of PHI and HIPAA information.