Appeals Specialist I
Job ID 2013-21989 # Positions 1
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 2/8/2013
Additional Locations ..
More information about this job:
Under direct supervision, processes all levels of member and provider medical appeals and payment appeals/disputes. Interacts with various departments to coordinate the medical appeal process and resolve payment appeals issues. Receives documents, investigates, refers and coordinates grievances and appeals. Initiates case files for each grievance and ensures compliance with organizational and regulatory requirements.
1. Identify and coordinate/route medical appeals accurately and timely. Provide all administrative related information and route accordingly for proper clinical review.
2. Research and resolve payment related issues and properly identify root cause of appeal. This includes data entry of appeal state documentation and findings in designated tracking systems, coordinating with various departments when appropriate and communicating resolution to the appellant.
3. Ensure compliance with intra-related departments and contracts/regulations by utilizing accessible current guidelines and resources.
4. Analyze system authorization to ensure accurate data entry. This requires an understanding of Medical Management department’s administrative processes and guidelines.
5. Perform necessary claim adjustments as required per the appeal resolution. This includes advanced levels of claims transactions/claim types and coordination of benefits.
6. Build collaborative relationships with various departments’ contacts for assigned markets.
7. Respond to inquiries from other departments and document in proper system platform/database.
8. Meet or exceed productivity and quality standards.
9. Adhere to company and department policies and procedures.
10. Perform other duties as assigned.
EDUCATION AND EXPERIENCE
- High school diploma or GED
- Associate’s degree in business, health care or related field
Years and Type of Experience Required:
- Two years of claims research or appeals experience, or demonstrated proficiency as Claims Analyst.
Certifications or Licensures
Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard and 10 key.
- Use of internet, familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells).
- Ability to work in databases.
Office Math Skills
- Ability to process numbers, which is an essential skill for any problem solving situation in a claims environment.
- Skills in the use of a calculator (using percentages, multiplication and division) to determine appropriate benefit payment.
- Ability to calculate the manual pricing of claims. Skills to verify accuracy with visual percentage calculations. Read, Interpret and Apply information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process claims.
- Capacity to follow step-by-step and general directions, remain detail oriented and verify data including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contracts for outpatient and inpatient claims.
- Ability to prepare written communication to providers documenting the results of their inquiry.
Medical & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Working knowledge of Medicaid and Medicare benefits.
- Familiarity with claims medical coding.
- Knowledge of the different standard claims forms used for physician and hospital billing.
- Understand COB and LTC processes.
- Knowledge of state and/or federal guidelines that apply to the Medicaid or Medicare benefits.
- Understand the different levels of care and applicable payment methodology.
Claims System Familiarity
- Understanding of the claims payment system.
- Ability to access documentation through the use of an image repository-review system, such as Macess.
- Ability to apply multiple market information and process high dollar claims due to authorization level.
- High level understanding of system configuration for benefits, pricing, and provider set up.
- Ability to identify system issues to management for problem solving.
- Demonstrates understanding of the organization's mission and strategies.
- Works to clarify and understand the broader purpose and mission of own work.
- Integrates and balances big-picture concerns with day-to-day activities.
- Generates innovative ideas and solutions to problems.
- Identifies opportunities to increase efficiency, simplicity, and revenue.
Make Sound Decisions
- Approaches problems with curiosity and open-mindedness.
- Collects sufficient information to understand problems and issues.
- Analyzes problems and issues from different points of view.
- Applies accurate logic and common sense in making decisions.
People Leadership Develop/Support Organizational Talent
- Relates to people in an open, friendly, and accepting manner.
- Treats others with respect.
- Listens carefully and attentively to others’ opinions and ideas.
- Maintains positive relationships even under difficult or heated circumstances.
- Works cooperatively with people from different cultural backgrounds.
- Encourages people to draw on each other's strengths and experience to work together effectively, within and across teams.
- Appropriately involves others in decisions and plans that affect them.
- Provides honest, helpful feedback to others on their performance.
- Shares own experience and expertise with others.
Results Leadership Show Drive and Initiative
- Demonstrates a "can-do" spirit, a sense of optimism, ownership, and commitment.
- Maintains a consistent, high level of productivity.
- Takes personal responsibility to make decisions and take action.
- Does not easily give up in the face of unexpected obstacles.
- Projects a positive image and serves as a role model for others.
Accountability / Optimize Execution
- Juggles many priorities and competing demands for one's time.
- Acts resourcefully to ensure that work is completed within specified time and quality parameters.
- Removes obstacles in order to move the work forward and/or get efforts back on track.
- Surfaces problems and issues before projects get derailed.
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.
AMERIGROUP Corporation - 22 months ago
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AMERIGROUP looks after the health of America's needy. The managed health care provider targets people eligible for Medicaid, the State...