We are seeking a dynamic and experienced Appeals Specialist to join our team, playing a pivotal role in our accounts receivables department. The ideal candidate will conduct thorough reviews of medical records and draft compelling appeals to insurance companies based on ASAM, LOCUS, federal, and/or commercial insurance guidelines.
Responsibilities:
· Responsible for conducting medial record reviews and responding to both clinical and administrative denials in a timely manner
· Composes and submits all required documentation (including appropriate medical records to support medical necessity) for a reconsideration, appeal, or retro authorization to the insurance carrier via payer portal, fax or mail
· Collaborates with other departments/resources/entities as applicable to ensure the most optimal appeal outcome.
· In collaboration with multi-departmental subject matter experts, identify denial trends and patterns and creates education and guidance on root causes and any preventable measures that can be put in place
· Utilizes appropriate applications to accurately track clinical denial data, participates in the development and implementation of a system-wide process for appeals to include tracking of success rates
· Maintains strong working knowledge of any payer guidelines & appeals processes, including any state and regional requirements
· Provides recommendations and education to CDI, Coding, and RCM leadership as a result of process and documentation improvement opportunities that are resulting in clinical denials.
· Gathers and fill out any payer specific forms and letters
· Apply clinical and industry guidelines, and use of in-depth knowledge that supports medically necessity of services rendered
· Meet success rate metrics for appeal outcomes
· Effectively manage and work to maintain timely responses to denials within specific deadlines
Qualifications
- 2+ years experience in behavioral health/substance abuse industry
- 2+ years of auditing or medical review experience, preferred
- Highly organized and able to track workflows through various tools
- Excellent communication skills, both written and spoken
- Knowledge of health care evaluation methodology, medical terminology, and regulations
- Strong organization and data management skills, including word processing, spreadsheets, monitoring and evaluation tools
- Strong time management and critical thinking skills
Preferred Experience: Knowledge of any of the following EMR/Billing Softwares: Kipu, Best Notes, Alleva, NetSmart/MyAvatar, Medsphere, Sunwave, CollaborateMD
Job Type: Full-time
Pay: $22.00 - $28.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Healthcare setting:
- Clinic
- Inpatient
- Outpatient
- Telehealth
Medical specialties:
Schedule:
- 8 hour shift
- Day shift
- Monday to Friday
Work Location: Remote