Appeals Specialist

Quadax, Inc.•Middleburg Heights, OH

About The Position

This role involves reviewing assigned denials and Explanation of Benefits (EOBs) to gather information for filing appeals. The specialist will determine appeal strategies based on case history, payer history, and state requirements. Key responsibilities include obtaining necessary consents and medical records, completing special appeal forms, creating and mailing appeal letters, and coordinating phone hearings. The position requires strict adherence to all levels of appeal processes, system, and documentation Standard Operating Procedures (SOPs), as well as meeting all filing deadlines. The specialist will also report on insurance company or state requirements and denial trend changes, participate in team meetings, and act as a backup for incoming calls. Special projects may be assigned, and the ability to meet predetermined productivity goals and quality standards (90% or greater) is essential. Other duties as assigned.

Requirements

High School diploma or GED
Minimum of four years health insurance billing experience
Knowledge of managed care industry including payer structures, administrative rules, and government payers
Proficient in all aspects of reimbursement
Ability to maintain confidentiality
Detail oriented
Possess excellent written and verbal communication skills
Able to establish priorities, work independently, and proceed with objectives without supervision.
Proficient in using Microsoft Excel and Word

Responsibilities

Review assigned denials and EOB’s for appeal filing information and gather any missing information.
Review case history, payer history, and state requirements to determine appeal strategy.
Obtain patient and/or physician consent and medical records when required by the insurance plan or state.
Gather and fill out all special appeal or review forms.
Create appeal letters, attach the materials referenced in the letter, and mail them.
Coordinate phone hearings with the insurance company, patient, and physician.
Comply with all 1st, 2nd, 3rd, and External Level Appeal process, system, and documentation SOP’s.
Meet appeal filing deadlines by completing assigned worklist tasks in a timely matter and/or reporting to management when assistance is needed to complete the tasks.
Report all insurance company or state requirements and denial trend changes to the Team Leader and Reimbursement Manager.
Participate in team and appeal meetings by sharing the details of cases worked.
Act as a backup on answering incoming telephone calls as needed.
May undertake special projects assigned by the Team Leader or Reimbursement Manager.
Ability to meet predetermined Productivity Goals based on the level of Appeal.
Ability to meet Quality Standard in place (90% or greater).
Other duties as assigned.