Post-Service Appeals Case Manager

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

📋 Description

• Manage post-service medical necessity appeals for DME claims independently, from initial denial review to final resolution.

• Analyze denied claims by reviewing denial rationale, documentation gaps, authorization challenges, and strategies for appeal.

• Examine medical records and clinical documentation to evaluate medical necessity and payer coverage standards.

• Investigate and interpret payer policies, medical necessity guidelines, coverage standards, reimbursement criteria, and appeal processes.

• Prepare and submit first-level, second-level, and other relevant appeals within specified deadlines.

• Compose clear and clinically supported appeal letters that address denial reasons and medical necessity.

• Acquire missing clinical documentation from healthcare providers and clinical teams.

• Engage in communication with insurers, payer representatives, and claims departments regarding appeals and determinations.

• Monitor submissions, correspondence, follow-ups, deadlines, decisions, and outcomes meticulously.

• Keep precise case notes and patient information in CRM, billing, and case management systems.

• Utilize knowledge of benefit investigations, prior authorizations, retro-authorizations, claims workflows, and appeals.

• Collaborate with Billing and Reimbursement teams to discuss appeal status and subsequent steps.

• Assist with prior authorization and other reimbursement appeals as necessary.

• Identify trends in denials and documentation deficiencies; report findings and opportunities for process enhancement.

• Provide leadership reports on denials, appeal outcomes, payer trends, and process improvements.

• Educate providers and internal stakeholders on documentation requirements and reasons for denials.

• Work together with Patient Access, Reimbursement, Billing, Clinical, and cross-functional teams.

• Create and maintain payer resources, appeal templates, tools, and training materials.

• Meet expectations for quality, accuracy, productivity, and turnaround times.

• Uphold patient confidentiality and adhere to company policies, HIPAA, and privacy regulations.

⛳️ Requirements

• Bachelor's degree in Business, Healthcare Administration, Health Sciences, or a related field preferred; equivalent relevant experience will be considered.

• At least 5 years of experience in the healthcare industry, ideally in medical device, DME, reimbursement, patient access, billing, or related areas.

• Minimum of 2 years of experience in medical device reimbursement involving DME products.

• Proven experience managing post-service appeals, claim denials, or medical necessity appeals.

• Knowledge of DME reimbursement, benefit investigations, prior and retro-authorizations, claims processing, and appeals.

• Ability to independently research and interpret payer policies, medical necessity criteria, coverage requirements, and appeal procedures.

• Experience in reviewing clinical documentation and assessing support for medical necessity.

• Capability to independently prepare, submit, track, and follow up on complex appeals.

• Understanding of payer deadlines and the importance of timely, accurate submissions.

• Strong analytical and problem-solving abilities for addressing complex claims issues.

• Excellent written communication skills for creating clear, persuasive, and clinically supported appeal documentation.

• Strong verbal communication and collaboration skills.

• Exceptional organizational and case management skills; ability to handle a high-volume workload and multiple deadlines.

• Keen attention to detail and a commitment to accuracy and compliance in documentation.

• Preferred: direct experience with post-service DME appeals, multi-level payer review, commercial and government payers, payer medical policies, retro-authorization, denial trend analysis, CRM/billing/case management systems, Salesforce, cross-functional healthcare collaboration, payer resources/templates/training documentation, and experience in high-growth medical device or healthcare organizations.

🏝️ Benefits

• Comprehensive health insurance options.

• Opportunities for professional development and career advancement.

• Flexible working arrangements to promote work-life balance.

• Supportive team culture and collaborative work environment.