Appeals Specialist (3279)

THE COUNSELING CENTER•Portsmouth, OH

3d•$19 - $25•Onsite

About The Position

The Appeals Specialist is responsible for reviewing insurance denials and preparing comprehensive appeal submissions for behavioral health, substance use disorder, primary care, and ancillary services. This position serves as a liaison between clinical staff, billing, compliance, and insurance payers to maximize reimbursement through timely and well-supported appeals. The specialist analyzes denial trends, researches payer policies, prepares appeal packets, coordinates peer-to-peer reviews, and ensures all appeal activities comply with payer requirements and regulatory standards.

Requirements

High school diploma or GED required
Minimum of two years of experience in healthcare appeals, medical billing, denial management, utilization review, or revenue cycle.
Knowledge of Medicaid, Medicare, Managed Care Organizations, and commercial insurance appeal processes.
Strong understanding of medical necessity criteria, payer policies, and reimbursement guidelines.
Excellent written communication skills with the ability to prepare persuasive appeal documentation.
Strong organizational skills and the ability to manage multiple deadlines.
Proficiency with Microsoft Office and electronic health record systems.

Nice To Haves

Associate's or Bachelor's degree preferred.
Experience with behavioral health or substance use disorder services preferred.
Experience with Ohio Medicaid behavioral health services.
Knowledge of ASAM Levels of Care and behavioral health documentation standards.
Experience working with Ohio Medicaid Managed Care Organizations, including CareSource, Buckeye, Molina, AmeriHealth Caritas, Humana Healthy Horizons, and UnitedHealthcare Community Plan.
Experience using payer portals such as Availity and other insurer-specific systems.
Experience with NextGen or other behavioral health electronic health record systems.

Responsibilities

Review denied claims and authorization decisions to identify the reason for denial.
Analyze payer policies, provider manuals, medical necessity criteria, and applicable federal and state regulations.
Prepare first-level, second-level, expedited, and external appeal submissions.
Draft clear, concise, and evidence-based appeal letters using clinical documentation and payer-specific guidelines.
Coordinate peer-to-peer reviews between providers and payer medical directors when appropriate.
Monitor appeal filing deadlines and ensure timely submission of all appeal documentation.
Track appeal outcomes and communicate decisions to appropriate clinical, billing, and leadership staff.
Maintain organized records of all appeal activity and supporting documentation.
Escalate recurring denial trends and reimbursement concerns to leadership.
Collaborate with billing, compliance, utilization management, and clinical teams to reduce preventable denials.
Review denial reports to identify patterns, root causes, and opportunities for process improvement.
Recommend corrective actions to improve documentation, coding, and billing practices.
Assist with payer audits and provide supporting documentation related to appealed claims.
Participate in denial prevention initiatives by educating staff on common denial reasons and payer expectations.
Maintain accurate records of appeal submissions, correspondence, and payer determinations.
Document all payer communications within the electronic health record or designated tracking system.
Generate reports related to appeal volume, appeal turnaround times, appeal success rates, denial trends, outstanding appeals, and financial recovery resulting from successful appeals.
Provide regular updates to leadership regarding appeal performance and denial trends.
Ensure compliance with Ohio Department of Medicaid requirements, OhioMHAS regulations, Medicare regulations, Managed Care Organization (MCO) policies, HIPAA Privacy and Security Rules, 42 CFR Part 2, and CARF, Joint Commission, and other accreditation standards, as applicable.
Stay current on payer policy updates, regulatory changes, and industry best practices related to appeals and reimbursement.
Performs any other duties as assigned by Department Leadership.