Clinical Appeals Specialist - Clinical Appeals

CHRISTUS Health • Houston, TX

3d

About The Position

The Clinical Appeals Specialist works independently to research and review inquiries from members and providers. The role requires knowledge of benefit interpretation, claims review, and CPT and ICD coding, and is responsible for analyzing, researching, and managing member and provider appeal and grievance inventories. The specialist responds to inquiries verbally and in writing.

The specialist researches and resolves claim denials, complaints, and reconsideration and redetermination requests; reviews and responds to complaints, grievances, and appeals within applicable time frames; and works toward 95% compliance with CMS guidelines while adhering to state and federal regulations and internal policies. The role also involves communicating with associates to support accurate, timely responses; educating members and providers about plans and appeal and grievance processes; and confirming appropriate reimbursement under Medicare policies and procedures.

Requirements

• Bachelor's degree or equivalent years of relevant work experience.
• At least five years of healthcare customer service, claims, denials, appeals, compliance, or related experience.
• Strong background in healthcare.
• Experience with Microsoft Office, including Word and Excel.
• Knowledge of benefit interpretation, claims review, billing, collections, payments, refunds, accounts receivable, and claim denials.
• Knowledge of general medical terminology and CPT, ICD-9, and ICD-10 coding.
• Knowledge of or prior experience with Medicare Recovery Audits and managed care audit processes.
• Clear, concise verbal and written communication skills, phone etiquette, organizational skills, time management, decision-making, problem-solving, and multitasking ability.

Responsibilities

• Research and resolve claim denials, member and provider complaints, and reconsideration and redetermination requests.
• Review and respond to complaints, grievances, and appeals within the applicable time frames.
• Adhere to state and federal regulations, CMS guidelines, and CHRISTUS Health policies and procedures, with a stated 95% CMS-guideline compliance expectation.
• Communicate with associates to support accurate and timely responses to internal and external customer inquiries.
• Educate members, providers, and others about CHRISTUS Health plans, the appeal and grievance process, plan and contract terminations, and benefit summaries.
• Verify that providers and members are reimbursed appropriately using Medicare reimbursement policies and procedures.
• Communicate with multiple organizational levels, including managers, clinical staff, and support staff.
• Manage time and priorities, solve problems, make decisions, and contribute to process improvement.
• Work independently and as part of a team.

What This Job Offers

• Job Type: Full-time