Senior Appeals Specialist - Workers' Compensation
About The Position
Reliant Health Partners is an innovative medical claims repricing service provider, helping employers achieve maximum health plan savings with minimum noise. We tailor our services to each client’s needs, providing everything from individual specialty claims repricing, to full plan replacement as a high-performance, open-access network alternative. As a Senior Appeals Specialist – Workers’ Compensation, you will play a critical role in resolving post-payment disputes related to Workers’ Compensation bills. This includes conducting provider outreach, negotiating disputed charges, and ensuring compliance with state-specific regulations. Your work will directly support our cost containment efforts and ensure appropriate bill reimbursement for our clients.
Requirements
- 5 years of relevant experience in Workers’ Compensation bills, medical billing, medical coding, or insurance negotiations.
- Strong understanding of Workers’ Compensation reimbursement methodologies, state regulations, and provider billing practices.
- Experience negotiating medical bill payments or adjustments with providers.
- Ability to collaborate with a variety of individuals both internally and externally.
- Familiarity with claims processing systems and provider communications.
- Excellent communication, negotiation, and organizational skills.
- Requires communication proficiency, discretion, ethical conduct, decision making and technical skills
Responsibilities
- Manage a caseload of post-payment Workers’ Compensation bills, including those related to state disputes and usual and customary rate (UCR) disputes.
- Assigned high priority clients in managing all items related to the service with Reliant
- Conduct proactive outreach to medical providers to explain payment methodologies, resolve disputes, and negotiate reductions on appealed or outlier bills.
- Communicate effectively and professionally with clients to coordinate and investigate information as it relates to the case/appeal.
- Educate providers on Workers’ Compensation billing and reimbursement policies and regulatory requirements.
- Document all provider communications thoroughly, including contact information, bill details, proposed and counter-offered payment rates, and final resolution in claim platform.
- Adhere to state-specific compliance standards and confidentiality requirements, including HIPAA.
- Maintain productivity and quality standards, ensuring timely resolution of bills in accordance with state timelines and internal service level agreements.
- Follow client-specific protocols and internal Reliant procedures, including scripting and documentation guidelines.
- Stay current on Workers’ Compensation regulatory changes, fee schedules, and payment policies across multiple states.
- Support special projects and perform additional duties as assigned.
- Responsible for training team members both upon hire and for existing team members.
- Responsible for overseeing all DWD handling and state dispute referrals to attorneys.
- First line for all support with questions from other team members.
- Backup for other team members and/or senior leadership
- Works with appeals intake specialist to ensure process documents remain current
- Responsible for identifying opportunities for enhancement either through automation or process changes that increase efficiency for the team
- Responsible for team goals and ensuring that individuals meet their personal goals
Benefits
- Comprehensive medical, dental, vision, and life insurance coverage
- 401(k) retirement plan with employer match
- Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
- Paid time off (PTO) and disability leave
- Employee Assistance Program (EAP)
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
