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Appeals Analyst II - Healthcare

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Healthcare
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20763 Requisition #

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. 

Education and Experience: 
  • High School completed and with some university studies preferred.
  • Minimum of one to 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, etc.). Intermediate to advance level in Excel.
  • Knowledge of the health care professional services billing (physicians and related health care professionals) and reimbursement environment.
  • Knowledge of medical terminology.
  • Knowledge of networks, IPAs, MSOs, HMOs, PPOs and contract affiliations preferred.
  • Knowledge of managed care contracts and compliance preferred.
 
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 multiple computer applications.

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