Provider Appeals Representative

Baystate Health•Springfield, MA

9d•Remote

About The Position

The Provider Appeals Representative is responsible for the timely review and resolution of post claim review provider appeals, including providing advice and assistance to the Provider Relations Representatives on complex issues. This position will address business problems and issues discovered during the course of an appeal review, and with the help of the Sr. Provider Appeals Representative. Works with other HNE departments to effect changes to HNE policies. The Provider Appeals Representative will propose or suggest training opportunities for other departments on the provider appeals process to the Provider Relations Manager

Requirements

Associate’s degree and a minimum of 3 years’ experience in a managed care organization
Demonstrated listening and customer service skills
Strong verbal and written communication skills
Problem resolution skills
Solid interpersonal and negotiation skills
Strong Multi-tasking and detail oriented skills
Proficient with the Microsoft suite of products

Nice To Haves

Experience specific to provider relations or complaints & appeals.
Knowledge of CPT and ICD, DRG and HCPC coding systems as well as industry standard including CMS
Knowledge of Amisys Coding

Responsibilities

Researches, reviews, responds, and recommends action for all provider appeals; work closely with Claims Analyst, Appeals & Policy Nurse, Behavioral Health and appropriate department managers on reviewing appeals and supplying adequate information to make decisions/recommendations as needed
Communicates with providers and HNE staff to gather info for the decision making process of the appeal. Makes a recommendation for disposition of the appeal and prepare and prepares a response letter, signs decision letters, and handles inquiries from providers.
Provides education on benefits and/or process to our provider network as well as acting as a resource on complex claim services
Presents provider education or root cause to cause to Provider Relations Manager
Acts as a resource for the Provider Relations Representative, Claims, Member Services Departments and Appeals & Policy Nurse with regard to post claim reviews claim reviews, and Provider Appeals database.
Coordinates as well as supports efforts with various internal departments
Works with Provider Relations Manager to identify, suggest, and implement improvements to minimize invalid provider appeals
Adheres to reporting requirements for DOI, Medicare and Medicaid
Utilizes the Provider Appeals reporting tool to track appeal turn-around times, outcomes, external review statistics review statistics, etc. to assist other HNE departments
Adheres to processes around the database to capture trends and data on invalid/valid appeals
Provides information to provider network on Provider appeals status and determination
Proactively identifies, suggests. and/or proposes provider network opportunities and training needs
Identifies, suggests, and implements improvement to Provider Appeals materials on an ongoing basis
Participates in HNE work groups, committees and projects as assigned
Works collaboratively with HNE internal departments to ensure-performance guarantees are met
Serves as back-up on Provider Relations phone queue