Job Description

Description The Healthcare Appeals Analyst is responsible for monitoring contractual allowances, analyzing and pursuing appeal opportunities with payers and networks, and reporting appeals performance. Essential Functions: • Implements process for identifying under-allowed claims using software and other available tools. • Reviews and analyzes EOBs for identified under-allowed claims. • Verifies applicable contract by, as dictated by operational procedures: reviewing EOB messages, reviewing patient ID card, verifying member information for managed care plans. • Uses feedback and experience to refine communication skills and tools for use in preparing written and telephone appeals. • Batches appeals by payer or network, by CPT/HCPCS code combination, by error type, or by provider. • Compiles and submits appeals, and monitors for proper reimbursement. • Uses software to track appeals and recoveries. • Establishes and cultivates helpful and effective contacts in payer or network offices. • Establishes follow-up protocol with payers and networks. • Prepares monthly performance statistics regarding appeals and recoveries. • Monitors and tracks contractual, billing, registration, and posting errors, and provides continuous feedback to Appeals Manager. • Participates in meetings to discuss ongoing trends and issues regarding the administration of managed care contracts. • Maintains the strict confidentiality required for medical records and other data. • Participates in professional development efforts to ensure currency in managed care reimbursement trends. Knowledge, Experience & Qualifications Education and Experience: • Associates degree preferred • Minimum of two years’ experience working with managed care claims and appeals for health care professional services (physicians and other health care professionals). • Experience in a production environment desirable but comfort in such an environment is essential. Equivalent combination of education and experience may be considered Knowledge: • Advanced knowledge and PC skills, with proficiency in utilizing Microsoft office products (Word, Excel, Outlook, PowerPoint, etc.) • Knowledge of the health care professional services billing (physicians and related health care professionals) and reimbursement environment. • Knowledge of major types of practice management system (PMS) and EOB imaging systems, with experience working with at least one industry leading PMS highly desirable. • Knowledge of medical terminology. • Knowledge of networks, IPAs, MSOs, HMOs, PCP and contract affiliations. • Knowledge of managed care contracts and compliance. Skills: • Demonstrated skill in gathering and reporting claims information. • Demonstrated skill in written and oral communication with colleagues, supervisors, and payer/network personnel. • Demonstrated skill working in a team-oriented structure to achieve goals. • Demonstrated skill in problem solving and research. Abilities: • Ability to work effectively with other departments and management. • Ability to identify, analyze and solve problems and to recognize patterns in data. • Ability to learn, understand and use the software application.

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