Senior Appeals Specialist

Quadax Careers & Culture•Middleburg Heights, OH

About The Position

This role involves working across various appeal worklists, with a potential focus on specific insurance companies. The Senior Appeals Specialist will be responsible for identifying and communicating denial and appeal trends to internal teams and clients. This position requires acting as a subject matter expert in insurance appeals, obtaining necessary patient information and medical records, and creating/submitting appeal letters according to client Standard Operating Procedures (SOPs). The role also includes maintaining appeal forms, documenting processes, participating in team meetings, training new team members, and undertaking special projects. Key performance indicators for productivity and quality must be met or exceeded. The position also requires working with global teams, understanding payer projects, and potentially obtaining Lean Six Sigma (LSS) certification.

Requirements

High School diploma or GED
Minimum of four years’ health insurance billing experience, or equivalent degree
Minimum of one-year Quadax production experience
Proficient with PAS and HARP systems
Excellent written and verbal communication skills
Knowledge of managed care industry including payer structures, administrative rules, and government payers
Proficient in all aspects of reimbursement
Able to work independently and prioritize tasks
Ability to maintain confidentiality
High attention to detail
Possess excellent written and verbal communication skills
Able to establish priorities, work independently, and proceed with objectives without supervision
Proficient computer skills with knowledge of Microsoft Excel and Word

Nice To Haves

Lean Six Sigma (LSS) Yellow Belt or higher certification (to be obtained in the role)

Responsibilities

Work as needed in all appeal worklists, potentially with a focus on contracted or sensitive insurance companies.
Communicate denial and appeal trends to client engagement and payer relations teams.
Serve as an SME (subject matter expert) in insurance appeals matters and work with management to relay updates to clients.
Obtain patient consent and medical records for appeal when required by the insurance plan.
Gather updated appeal or review forms to add to form library.
Create appeal letters, attach the materials per client SOP, and submit via portal/fax/mail.
Comply with all appeal process documentation and SOPs.
Participate in team meetings, sharing case details.
Provide the best practices for other team members.
Train new or less experienced appeals team members.
Undertake special projects assigned by Production Management or client.
Review denials and EOBs for appeal filing information, gathering any missing details.
Inform management of incorrect or missing appeal default information.
Fill out special appeal or review forms.
Initiate payer projects, complete as assigned, including creating and maintaining tracking spreadsheets.
Ability to work on additional work lists as needed.
Work directly with global teams to demonstrate processes.
Once in the role, work to obtain Lean Six Sigma (LSS) Yellow Belt or higher.
Meet or exceed productivity and quality KPI goals.
Perform other duties as assigned.