Appeals Specialist

Job Description:

Responsible for researching and appealing denied medical claims. Responsible to proactively identify insurance denial trends and to then work with Payer Contracting on these issues. Responsible to know State/Federal/ERISA and self funded insurance laws so that they can file the appropriate appeal based on the law that applies.

This is a 100% remote position however, currently we are unable to consider candidates for remote opportunities in the following states: California, Hawaii, Rhode Island, Vermont, Connecticut and Washington.

Schedule - Monday - Friday hours are flexible between 6 am - 6 pm.

• Understands and uses various contracts and laws (i.e., ERISA, self-funded, State and Federal insurance) to appropriately appeal medical claims that have been denied.
• Conducts and refers patient accounts when requested by payers, audit firms, patient and RCO departments to determine the appropriateness of billed charges, chargemaster data, revenue cycle data and UB/HCFA1500 information that is on the claim.
• Understands and identifies the true reason of the denial and looks at payer contracts, clinical data and other data to be able to appeal in a correct and concise way.
• Assesses the appropriateness of clinical appeal requests by working with and using evidence based utilization review criteria, payer policies and Federal and State regulations.
• Refers appeal cases to the designated Physician Advisor and works with them for obtaining support for appeals.
• Collaborates with Care Management, Physician Advisors, Revenue Integrity, Compliance, legal counsel, and RSC teams to prepare appeals.
• Identifies trends and opportunities for denial prevention and collaborates with the appropriate multidisciplinary teams to improve denial management, documentation, and appeals process.
• Supports legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process.
• Serves as a subject matter expert, resource and mentor to others within the RCO, clinical departments, Appeal RN’s, legal, IPAS and Payor Contracting on the art of appealing.
  
  

Minimum Qualifications

• 2+ years Revenue Cycle Experience
• Bachelor’s degree (BSN) is preferred.
  
  

Preferred Qualifications

• Two years of experience in and extensive knowledge in the health insurance industry (Commercial Insurances, Medicare, Medicaid); health claims billing or Third-Party contracts.
• Demonstrated excellent analytical, fact-finding, problems solving, and organizational skills as well as the ability to communicate, both verbally and in writing with staff, patients, and insurance plan administrators.
• Experience in conducting research and making educated, professional, and independent decisions and flexible and adaptable to ongoing change.
• Self-motivated and experienced in working without direct supervision.
• Demonstrated ability to proactively resolve varied and complex issues.
• Experience in working as a contributing team member and providing feedback to ensure best practices are discovered and implemented.
  
  

Physical Requirements:

Anticipated job posting close date:

07/08/2024

Location:

Lake Park Building

Work City:

West Valley City

Work State:

Utah

Scheduled Weekly Hours:

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$21.20 - $32.26

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits packages for our Idaho, Nevada, and Utah based caregivers, and for our Colorado, Montana, and Kansas based caregivers; and our commitment to diversity, equity, and inclusion.

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.