Job Description

Job Summary 

The Remote Medical Appeals Specialist is responsible for reviewing patient accounts denied for insurance reimbursement or paid incorrectly and following through with the appeal process to secure payment. This role requires effective communication, thorough research of claims, and collaboration with financial service units to resolve discrepancies and improve reimbursement rates. 

Essential Functions

Reviews denied claims and incorrect payments, initiating the appeals process to secure appropriate reimbursement from insurance carriers. Communicates with patient financial service units to ensure accurate processing of accounts, including revisions and payment schedules. Collaborates with appeals representatives to meet departmental demands, demonstrating flexibility and teamwork to support workload management. Researches and resolves claim discrepancies, including underpayments, incorrect denials, and incomplete charges, using knowledge of revenue codes, HCPC codes, and insurance guidelines. Analyzes explanation of benefits (EOBs) from various carriers to identify and address payment discrepancies, ensuring compliance with insurance contracts and guidelines. Responds to inquiries from other departments and insurance carriers, providing timely updates on claim status, additional documentation needs, and resolution strategies. Works closely with the Managed Care Department to address ongoing issues with contracted insurance companies, supporting improvements in claim management. Maintains accurate logs and reports of outstanding appeals, providing regular updates to leadership on claim status and outcomes. Assists case workers with pre-certification and authorization issues related to appeals, providing necessary data for resolving inpatient/clinical denials. Performs other duties as assigned. Complies with all policies and standards.

Qualifications

H.S. Diploma or GED required Associate Degree in Healthcare Administration, Business, or a related field preferred 1-3 years of experience in claims processing, healthcare billing, or revenue cycle management required

Knowledge, Skills and Abilities

Basic knowledge of medical billing, coding systems, and insurance claim processes. Strong communication skills for interacting with insurance carriers, patient financial service units, and other departments. Detail-oriented, with strong organizational and time management skills to manage a high volume of appeals. Proficiency in using healthcare billing software and Google Suite.