RCO Appeals Specialist

Intermountain Health • Lake Park, IA

1d • $22 - $33

About The Position

The RCO Appeals Specialist is responsible for researching and appealing denied medical claims. Responsible to proactively identify insurance denial trends and to then work with Payer Contracting on these issues. We are committed to offering flexible work options where approved and stated in the job posting. However, we are currently not considering candidates who reside or plan to reside in the following states: California, Connecticut, Hawaii, Illinois, New York, Pennsylvania, Rhode Island, Vermont, and Washington. Colorado for remote caregivers’ whose assigned Intermountain facility or service area is not based in Colorado. Please note that a video interview through Microsoft Teams will be required as well as potential onsite interviews and meetings Essential Functions Understands and uses various contracts and laws (i.e., ERISA, self-funded, State and Federal insurance) to appropriately appeal medical claims that have been denied. Conducts and refers patient accounts when requested by payers, audit firms, patient and RCO departments to determine the appropriateness of billed charges, chargemaster data, revenue cycle data and UB/HCFA1500 information that is on the claim. Interpret and accurately identify the true reason of the denial and review payer contracts, clinical data and other data to be able to appeal in a correct and concise way. Assesses the appropriateness of clinical appeal requests by working with and using evidence- based utilization review criteria, payer policies and Federal and State regulations. Refers appeal cases to the designated Physician Advisor and works with them to obtain support for appeals. Collaborates with Care Management, Physician Advisors, Revenue Integrity, Compliance, legal counsel, and RSC teams to prepare appeals. Identifies trends and opportunities for denial prevention and collaborates with the appropriate multidisciplinary teams to improve denial management, documentation, and appeals process. Supports legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process. Serves as a subject matter expert, resource and mentor to others within the RCO, clinical departments, Appeal RN’s, legal, IPAS and Payor Contracting on the art of appealing.

Requirements

• Demonstrated experience in a healthcare revenue cycle role
• Demonstrated proficiency in computer skills including Microsoft Office, internet and email
• Demonstrated experience in a role utilizing exceptional written communication skills
• Demonstrates knowledge of State/Federal/ERISA and self-funded insurance laws
• Medical billing
• Interpersonal skills
• Communication
• Healthcare Regulations
• Insurance regulations
• Medical terminology
• Critical thinking
• Problem solving
• Patient advocate
• Collaboration

Nice To Haves

• Demonstrated experience in healthcare insurance billing, follow-up, denials and appeals or audit role.
• Bachelor’s degree preferred.
• Experience with Epic preferred.

Responsibilities

• Understands and uses various contracts and laws (i.e., ERISA, self-funded, State and Federal insurance) to appropriately appeal medical claims that have been denied.
• Conducts and refers patient accounts when requested by payers, audit firms, patient and RCO departments to determine the appropriateness of billed charges, chargemaster data, revenue cycle data and UB/HCFA1500 information that is on the claim.
• Interpret and accurately identify the true reason of the denial and review payer contracts, clinical data and other data to be able to appeal in a correct and concise way.
• Assesses the appropriateness of clinical appeal requests by working with and using evidence- based utilization review criteria, payer policies and Federal and State regulations.
• Refers appeal cases to the designated Physician Advisor and works with them to obtain support for appeals.
• Collaborates with Care Management, Physician Advisors, Revenue Integrity, Compliance, legal counsel, and RSC teams to prepare appeals.
• Identifies trends and opportunities for denial prevention and collaborates with the appropriate multidisciplinary teams to improve denial management, documentation, and appeals process.
• Supports legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process.
• Serves as a subject matter expert, resource and mentor to others within the RCO, clinical departments, Appeal RN’s, legal, IPAS and Payor Contracting on the art of appealing.

Benefits

• We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
• Learn more about our comprehensive benefits package here.
• Intermountain Health’s PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution. The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates. Caregivers are eligible to participate in PEAK on day 1 of employment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees