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Why You'll Love This Job

Position Summary:   We are looking to hire a highly efficient denials and appeals specialist.  The denials and appeals specialists are responsible for timely and accurate resolution of insurance claim denials. The denials and appeals specialist will use payor guidelines, carrier websites, and coding edits tools to determine the appropriate steps needed to resolve the denial and submit appeals. To be successful as a denials and appeals specialist, you must be detailed oriented and provide clear and concise documentation. You should have an excellent understanding and utilization of payer contracts and provider manuals. You should be able to calculate the expected claim reimbursement. 

 

 

Major Responsibilities: 

  • Research denials and determine if there is a legitimate case for overturning the denial. 
  • Verify that all pertinent documentation which substantiates the appeal arguments are organized and complete, and that the appeal letter is logically argued. Ensure the documentation utilized is recorded according to internal quality standards. Use the best, most compelling evidence available to support the argument presented in the appeal. Recognize and obtain missing yet necessary documentation to complete the appeals package. Review and verify appeal exhibits/evidence for accuracy. 
  • Proof-read and edit the appeal letter, as necessary. Ensure appeal letter contains no spelling, grammatical, or syntax errors before being submitted to the client for review. 
  • Ensure that the appeal is written and submitted according to internal documentation control protocols and timely filing. 
  • Communicate and collaborate with internal and external team members to promptly, accurately, and professionally address any questions or concerns that arise because of the appeal review or writing and submission process and escalate customer concerns to management, as necessary. 
  • Inform manager of payor trends or problems or changes in payor requirements. 
  • Follow up on all Corrected claims and appeals submitted. 
  • Make clear, detailed notations in EMR system on all accounts worked.  
  • Calculate expected claim reimbursement. 
  • Have a working knowledge of payor policy guidelines and payor contracts.  
  • Have a clear understanding of fee schedules.  

 

All Responsibilities are essential job functions unless otherwise noted. 

Position Qualifications: 

  • High School Diploma.  
  • 2 years’ experience preferred.  
  • Excellent verbal and written communication skills.  
  • Excellent organizational skills and attention to detail.  
  • Maintains professional friendly attitude.  
  • Excellent knowledge of payor policies and guidelines.  
  • Familiarity with coding guidelines. 

 

 

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