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Medical Billing-Revenue Cycle - Appeal Specialist

The Appeal Specialist supports the functions of the Revenue Cycle Appeal team by assisting in the review of denied and underpaid claims for the formal appeal and dispute process with the payor. Responsibilities include, but are not limited to: Classification of appeals, research of accounts, preparing documents, obtaining appeal status, and review of appeal determinations.

Essential Functions/Duties

• Review Explanation of Benefits, denial letters and payor correspondence to classify type of appeal required.

• Gather, prepare, and review documentation & various forms needed to submit appeals correctly per payor guidelines.

• Engage patients via phone and/or mail to obtain requested information pertaining to the appeal process.

• Document the details, requirements, and deadlines of each individual appeal in billing software.

• Use reports to manage daily workflow and ensure accounts are processed within required timeframes.

• Timely and regular follow-up with payors regarding status of appeals.

• Ability to identify payor issues within the appeal process and discuss potential improvements and workflow solutions with leadership.

• Additional duties as assigned.

Education:

• High School diploma or equivalent

Skills:

• Knowledge of health care billing procedures, reimbursement, third party payer regulations, documentation, and standards. Knowledge of Blue Cross Blue Shield payors is a plus

• Understanding and interpretation of Explanation of Benefits (EOB) from payors

• Strong problem-solving skills, attention to detail, and ability to make timely decisions

• Excellent internal and external customer service skills

• Responsiveness and a strong commitment to meeting internal and external deadlines with limited supervision

Qualifications:

Required Experience

• Must be fluent in English

• Minimum of one (1) year of advanced medical billing experience

• Professional written and verbal communication skills

• Knowledge and experience of computers and related technology

• Ability to work independently with little or no direction and as a member of a team

Preferred (Not Required) Experience

• Minimum of one (1) year working in a call center environment

• Above average knowledge of insurance billing guidelines and policies

• Experience with Commercial Insurance appeal and reconsideration processes

• Experience with BCBS insurance a plus

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