Job Description

Job Title: CHS Appeals Specialist

Department: Revenue Cycle

Reports To: CHS Director, Denials

Job Summary: The CHS Appeals Specialist works as an integral part of the Revenue Cycle team. Responsible for the administration and coordination of the denial review and appeal management processes that includes evaluation of authorization denials, claims recovery, and denial root cause analysis. This position collaborates with all departments to ensure the denial management process includes the evaluation of all revenue cycle process that contributed to the receipt of a denial.

Job Responsibilities include:

• Make preliminary determination whether denial can be recovered as well as the need for additional appeal level submission.
• Research and prepare appeal files in response to authorization and low dollar medical necessity and plan limitation denials.
• Analysis of denials including identification of root cause.
• Resolve authorization and low dollar medical necessity and plan limitation denials, which include researching and reviewing payer guidelines, writing and submitting appeals with supporting documentation if required.
• Identifies coding, billing, or reimbursement errors/discrepancies with the denial or aging claim in order to escalate to the CHS Director, Denials.
• Evaluate denied dollars in comparison to the expected reimbursement for the identification payment discrepancies.
• Resolution of denial requiring benefit review to include writing appeals and preparing responses.
• Track and trend denials issues for escalation to leadership to assist with process improvement
• Special projects as assigned

Requirements:

Education:

• Associate’s degree, or equivalent experience (Preferred)
• In lieu of an Associate’s degree, a HS diploma (or equivalent) with 5 years of revenue cycle experience required.

Experience:

• Minimum 3 years revenue cycle and or denial management experience
• Knowledge of the managed care industry including payer structures, administrative rules, and government payers.
• Knowledge of insurance reimbursement, billing concepts and procedures, as well as laws and regulations affecting payment compliance, denials and appeals recovery.
• Knowledge of various reimbursement methodologies including, but not limited to, Per-Diem, DRG, fee schedule, percentage of charges, and stop loss.
• Proficient understanding of medical coding systems effecting the adjudication of claims payment. These include ICD-9, CPT, HCPCS, DRG, APG, APC, and revenue code structures.
• Ability to work collaboratively in a team environment or independently.
• Must be able to anticipate obstacles to a goal and initiates appropriate resolution.
• Must have initiative to identify barriers and opportunities and provides solutions through process and operational improvements.
• Proficient investigation and analytical skills.
• Able to communicate (both written and verbal) professionally and effectively.
• Requires exceptional attention to detail and demonstrated ability to prioritize work to ensure accuracy and timely completion.
• Ability to respond quickly to change
• Ability to build effective relationships across the System.
• Must be motivated to participate in the continued growth and development of Denial Management

Licensure:

• N/A

Physical Requirements:

• Lifting up to 20 pounds, standing or sitting for extended periods of time, as well as repetitive use of hands and fingers

• = Essential functions