JOB SUMMARY:

Initiates the appeal process, at the direction of Revenue Cycle management, until the case is overturned, appeal options are exhausted, or decision is made to discontinue process. This position assumes the responsibility for coordinating and appealing technical denials and working closely with the HIM Appeals Specialist responsible for clinical appeals.

• Ability to review and determine reason for insurance denial of claims
• Review and appeal unpaid claims daily and submit appeal timely.
• Develop appeal letters to substantiate overturning denial, i.e. coverage, authorization, non-covered services, contract issue, timely filing limit, etc.
• Develop and maintain detail denial inventory list
• Tracks and trends progress and outcomes of denial and appeal processes and compiles reports for Revenue Cycle leadership
• Completes follow-up work on appealed claims.
• Works with insurance carriers on appeal issues.
• Ensure clinical appeals are submitted to the HIM department
• Monitor the payments to assure reimbursement from third-party payers is accurate based on payer contract.
• Reviews denials for accuracy.
• Stays abreast of payer updates for authorizations, eligibility, etc and communicates to Revenue Cycle leadership
• Documents all activity in Revenue Cycle system.
• Attends continue education programs
• Other duties as assigned.

MINIMUM EDUCATION & EXPERIENCE

• High School education or GED required.
• 1-3 years of prior billing, collection, or appeals

KNOWLEDGE, SKILLS, & ABILITIES

• Knowledge of medical terminology.
• Clear and concise written communication skills and development of professional letters.
• Basic Microsoft Office knowledge.
• Ability to foresee projects from start to finish.

• Ability to review and determine reason for insurance denial of claims
• Review and appeal unpaid claims daily and submit appeal timely.
• Develop appeal letters to substantiate overturning denial, i.e. coverage, authorization, non-covered services, contract issue, timely filing limit, etc.
• Develop and maintain detail denial inventory list
• Tracks and trends progress and outcomes of denial and appeal processes and compiles reports for Revenue Cycle leadership
• Completes follow-up work on appealed claims.
• Works with insurance carriers on appeal issues.
• Ensure clinical appeals are submitted to the HIM department
• Monitor the payments to assure reimbursement from third-party payers is accurate based on payer contract.
• Reviews denials for accuracy.
• Stays abreast of payer updates for authorizations, eligibility, etc and communicates to Revenue Cycle leadership
• Documents all activity in Revenue Cycle system.
• Attends continue education programs
• Other duties as assigned