Senior Appeals Specialist

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