Appeals Specialist

LOCAL CANDIDATES ONLY POSITION IS FULL TIME IN OFFICE

Compliance Analysis and Appeal review

• Receives, investigates, and responds to appeals from hospitals.
• Research and obtain appropriate documentation to support the appeal.
• Review of UB04 and detailed itemized statements
• Review of automated system analysis
• Perform hospital coding analysis. e.g. Medically Unlikely Edits (MUEs), the Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT) and Diagnosis Codes.
• Review procedure/facility codes for unbundling, MUE's, multiple procedures, inpatient codes on outpatient bills, routine services, etc.
• Review of UB04 and detailed itemized statements
• Assist in Internal Code Creation
• Attend required staff training and meetings.
• Other special projects as needed.

Medical Review and Pricing Analysis

• Review medical record documentation as relates to the UB04 and itemized statement
• Identify compliance and billing errors as well as make appropriate documentation as relates to review performed
• Obtain hospital CMS certification information

KNOWLEDGE, SKILLS & ABILITIES

• Two-year experience in Microsoft Office and Excel programs
• Proficient data entry skills and accuracy
• Ability to follow procedures.
• Comprehension of hospital coding, billing guidelines and regulations, to include but not limited to, Medicare guidelines, application of Health Insurance Policies, and current industry standards.
• Exceptional attention to detail
• Excellent organizational, analytical, and problem-solving skill
• Capable of handling multiple projects in a fast-paced, hyper-growth environment
• Strong interpersonal and team-building skills

Experience and Training

• 1-2 years' experience as LPN or RN preferred.
• Certified Professional Coder (CPC), (CPMA) (preferred but not required)
• One or more years of experience working with healthcare claims that demonstrate expertise in ICD 9/10 Coding, HCPCS/CPT Coding, DRG and medical billing for an Insurance company and/or hospital.
• One or more years of experience performing medical record reviews is required.
• Medical Terminology
• Problem-solving skills to research and resolve discrepancies, denials, appeals.
• Medicare Appeals processing background. (Preferred)
• RAC Audit experience (Preferred but not required)
• Knowledge of Medical fraud/abuse healthcare laws (Preferred but not required)
• Rev cycle management (Preferred)