Description
This role involves reviewing and resolving medical claims appeals submitted by customers, clients, and healthcare professionals. The Appeals Processing Sr. Representative researches claim decisions against established payment guidelines, internal procedures, and regulatory requirements to determine whether claims were processed correctly or require adjustment.
Responsibilities
- Review incoming appeals from customers, clients, and healthcare professionals
- Research appealed items against standard operating claim payment procedures and/or state and federal regulations using IComply and Benefit Access
- Determine if the claim issue in question was paid correctly or needs an adjustment
- Adjust overturned appeals or route them for adjustment
- Manage personal inventory and aging using daily reports
- Prepare and route appeals requiring clinical review to the Clinical Appeals Team
- Create and issue documentation explaining appeal decisions
Qualifications
- High school diploma or equivalent required
- Knowledge of Proclaim/Facets systems, OneView, and iView is preferred
- Ability to manage multiple tasks and work under pressure in a fast-paced environment
- Excellent verbal and written communication skills
- Strong attention to detail and ability to work in multiple systems concurrently
- Strong organization and time management skills; effectively adapts to multiple and/or competing priorities
- Process improvement skills; ability to assess trends, processes, and barriers to drive positive outcomes for resolutions
If working from home, an internet connection with speeds of at least 10Mbps download/5Mbps upload through a cable broadband or fiber optic internet service provider is required.