Appeals Analyst - PFS CCD Revenue Integrity - Sharp Corporate - Day Shift - Full Time

Sharp HealthCare•San Diego, CA

18d

About The Position

The Appeals Analyst appeals claims paid below contracted rates and escalates payer contractual issues to payers and Sharp management. The role analyzes underpayment and denial inventory, prepares appeals and payment dispute requests (PDRs) for non-clinical claims, and supports efforts to improve revenue collection and prevent future underpayments and denials. The position works with payer explanations of benefits, contracts, payer websites, billing software, and an underpayment tool.

Requirements

High school diploma or equivalent.
Five years of experience in all areas of billing.
Four years of accounts management experience in a multispecialty medical group.
Strong analytical and mathematical skills for resolving underpayment inventory.
Detail orientation and a diligent work ethic.
Strong communication and interpersonal skills.
Ability to work as a team player.
Knowledge of benefits, covered services, managed care and contract payer reimbursement, and billing procedures for government and non-government insurance programs.
Familiarity with current regulations of affiliated payers.
Familiarity with Microsoft Excel.
Knowledge of ICD-9 and CPT-4 codes and basic medical terminology.

Nice To Haves

Bachelor's degree with an emphasis in finance, business administration, or economics.
Experience resolving difficult underpayment and denial issues, categorizing inventory by underpayment reason, identifying root causes and trends, and clearly and persuasively explaining issues to payers.

Responsibilities

File appeals and PDRs for non-clinical underpaid or denied claims, and maintain standardized letters for training account analysts.
Explain new legislation affecting underpayments and denials.
Identify and trend underpayment and denial issues for training and prevention.
Prepare ad hoc reports to reconcile inventory or identify opportunities to increase revenue collection.
Obtain and load current quarterly, monthly, and yearly insurance rates into the Contract Underpayment tool.
Prioritize appeals based on recovery potential, payer appeal deadlines, contract reimbursement, reason for underpayment or denial, facility, and patient type.
Meet projected collection goals and appeal productivity standards.
Maintain strong communication with supervisors and management and ensure work accuracy.
Review payer EOBs, contracts, payer websites, and other relevant information to support appeals.
Cross-train and file appeals for payers outside the assigned mix when a team member is absent.
Follow up directly on filed appeals within applicable timeframes.
Provide ongoing training and feedback to account analysts to improve initial appeal and PDR success rates.
Participate in management meetings to review appeal denial trends and determine next steps and resolution plans.
Perform other duties as assigned.