Appeals Specialist

TEKsystems•Happy Valley, OR

3d•$25 - $31•Remote

About The Position

Responsible for all activities associated with appeal analysis, decision-making and closure. This includes appeal intake, analysis, decision & closure, and overseeing the external review process. The role also involves interpersonal and communication skills to assist members and providers, systems and data tracking, and supporting appeal policies and procedures. The specialist will manage a caseload, adhere to timeliness and quality standards, and may act as an expert witness. They must meet timeliness standards set forth through department policies, procedures, subscriber summary plan descriptions, performance guarantees, and regulations.

Requirements

Excellent verbal and written communication skills.
Intermediate computer skills (e.g. Microsoft Word, Excel, Outlook) and experience with Regence systems.
Knowledge of medical terminology, anatomy and coding (CPT, DX, HCPCs).
Knowledge of Regence claims processing and clinical services operations.
Demonstrated initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing a course of action.
Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all aspects of internal and external contacts.
Ability to present complex medical and reimbursement information to others and to be diplomatic and persuasive regarding health plan benefits, claims and eligibility.
Ability to switch from one task or type of work to another as the business needs require.
Ability to effectively prioritize work to meet strict timelines while maintaining quality and consumer centric focus.
High school diploma or GED and a minimum 4 years experience in Regence Customer Service, Claims, or Clinical Services or equivalent combination of education and work experience.

Nice To Haves

Coding Certification preferred for Specialist I.

Responsibilities

Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal.
Document information in appropriate system.
Review claim coding and claim processing history, medical policy and reimbursement policies, regulatory and legal requirements, benefit contracts, and/or provider contracts.
Collect and catalogue supporting documentation and formulate an appeal recommendation.
Apply knowledge and experience to answer a variety of increasingly complex inquiries from members, providers, and provider representatives.
Collaborate effectively with coding specialists, appeal nurses, physician reviewers, and others as necessary to reach timely decisions on appeals.
Make non-clinical appeal determinations as permitted by department business processes and guidelines.
Follow departments processes to receive a clinical review and decision from licensed health professionals.
Present complex cases to appeal panels, document decisions, communicate determinations to members, providers or their representatives.
Oversee set-up of appeals for external review organizations, including document collection and coordination, communication with all parties, and other responsibilities as an intermediary between the provider and the external review organization.
Ensure external review information is documented in appropriate system.
Prepare letters and cases for external review as needed.
Implement external review decisions.
Provide information, education and assistance to members, providers, and their representatives.
Facilitate the members or providers understanding of the appeal process and of the information necessary to effectively process an appeal.
Be a courteous advocate to the member or provider when requesting supporting information.
Work cooperatively and effectively across all business areas to resolve.
Track appeals in appropriate systems and assist in the maintenance of files.
Assist with compilation of reports on appeals, including trends, number of cases, decisions, suggestions for process improvement, types of appeals, and compliance with timelines.
Support, apply and promote Provider or Member Appeal Policies & Procedures.
Adhere to dependability, customer focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all work.
Manage a defined caseload within department productivity and quality expectations and provide back up for other appeals staff.
May perform as expert witness during any level of appeal, regarding policies, procedures and member or provider appeal rights.
Meet timeliness standards as set forth through department policies and procedures, subscriber summary plan descriptions, performance guarantees, and regulations.