Key Responsibilities:
- Work as needed in all appeal worklists, potentially with a focus on contracted or sensitive insurance companies.
- Communicate denial and appeal trends to client engagement and payer relations teams.
- Serve as an SME (subject matter expert) in insurance appeals matters and work with management to relay updates to clients.
- Communicate denial and appeal trends to client engagement and client payer relations teams.
- Obtain patient consent and medical records for appeal when required by the insurance plan.
- Gather updated appeal or review forms to add to form library.
- Create appeal letters, attach the materials per client SOP, and submit via portal/fax/mail.
- Comply with all appeal process documentation and SOPs.
- Participate in team meetings, sharing case details. Provide the best practices for other team members.
- Train new or less experienced appeals team members.
- Undertake special projects assigned by Production Management or client.
- Review denials and EOBs for appeal filing information, gathering any missing details.
- Inform management of incorrect or missing appeal default information.
- Fill out special appeal or review forms.
- Initiate payer projects, complete as assigned, including creating and maintaining tracking spreadsheets.
- Ability to work on additional work lists as needed.
- Work directly with global teams to demonstrate processes.
- Once in the role, work to obtain Lean Six Sigma (LSS) Yellow Belt or higher.
- Meet or exceed productivity and quality KPI goals.
- Perform other duties as assigned.
Education/Experience:
- High School diploma or GED
- Minimum of four years’ health insurance billing experience, or equivalent degree
- Minimum of one-year Quadax production experience
- Proficient with PAS and HARP systems
- Excellent written and verbal communication skills
- Knowledge of managed care industry including payer structures, administrative rules, and government payers
- Proficient in all aspects of reimbursement
- Able to work independently and prioritize tasks
- Ability to maintain confidentiality
- High attention to detail
- Possess excellent written and verbal communication skills
- Able to establish priorities, work independently, and proceed with objectives without supervision
- Proficient computer skills with knowledge of Microsoft Excel and Word
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