Appeals Specialist
Alliance Healthcare Solutions - Middleburg Heights, OH

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Job Description:

The Appeals Specialist is responsible to respond to assigned second and third level denials by submitting appeal letters and required documentation to insurance companies within the appeal filing time limits. To submit external review requests and required documentation to the state within the filing time limits. Act as a patient advocate by identifying the path needed to obtain the maximum reimbursement under the insurance plan and work with the patient to get the denial overturned.

Key Responsibilities:
  • Review assigned denials and EOBs for appeal filing information. Gather any missing information
  • Review case history, payer history, and state requirements to determine appeal strategy
  • Obtain patient and / or physician consent when required by the insurance plan or state
  • Obtain medical records when required by the insurance plan or state
  • Gather and fill out all special appeal or review forms
  • Create appeal letters, attach the materials referenced in the letter, and mail them
  • Coordinate phone hearings with the insurance company, patient and physician
  • Comply with all 2nd, 3rd, and External Level Appeal process, system, and documentation SOPs
  • Meet appeal filing deadlines by completing assigned work list tasks in a timely matter and / or reporting to management when assistance is needed to complete the tasks
  • Report all insurance company or state requirements and denial trend changes to the Team Leader and Reimbursement Manager
  • Participate in team and appeal meetings by sharing the details of cases worked
  • Act as a backup on answering incoming telephone calls as needed
  • May undertake special projects assigned by the Team Leader or Reimbursement Manager
  • High School diploma or GED
  • Minimum of four years health insurance billing experience
  • Knowledge of managed care industry including payer structures, administrative rules, and government payers
  • Past leadership experience
  • Proficient in all aspects of reimbursement
  • Detail oriented
  • Possess excellent written and verbal communication skills
  • Able to establish priorities, work independently, and proceed with objectives without supervision.
  • Proficient in using Microsoft Excel and Word

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