Appeals Specialist

Overview

Job Title: Appeals Specialist

Reports to: Appeals Supervisor

Employment Status: Full-Time

FLSA Status: Non-Exempt

Work Location: On Site

The Appeals Specialist is responsible for all duties related to managing payor contracts, negotiation, and renegotiation of new and existing payor contracts. This position will be responsible for resolution of assigned cases, accurate and timely documentation of case actions, and assist in the oversight of delegates responsible for appeals and grievances functions. This position ensures contracts are appropriately identified, negotiated, implemented, audited, and renegotiated in a timely manner.

This position requires prior knowledge of Managed Care in a Provider or Payor setting in addition to understanding Payer Contracting tasks and activities in the substance abuse and behavioral health field.

• Review denied or underpaid medical claims for accuracy and compliance with payer guidelines
• Draft and submit written appeals to insurance companies or other payers, citing supporting medical documentation, coding references, and policy guidelines
• Monitor the status of submitted appeals and follow up to ensure timely resolution
• Analyze explanation of benefits (EOBs) and remittance advice (RA) to identify denial trends or coding issues
• Collaborate with billing and coding teams to correct errors and resubmit claims as needed
• Maintain detailed records of appeal activities and outcomes in the patient account management system
• Act as liaison between healthcare providers, patients, and insurance companies to resolve payment disputes
• Communicate effectively with physicians and other healthcare professionals to obtain additional documentation or clarification needed for appeals
• Participate in teams meetings and share insights on payer-specific denial trends or policy changes
• Ensure compliance with federal, state and payer-specific regulations, including HIPAA, ASAM, LOCUS and MCG
• Stay updated on changes in medical billing codes, payer policies, and reimbursement guidelines

• Strong knowledge of medical billing and coding systems, (CPT, ICD-10, HCPCS)
• Experience with insurance payer guidelines and appeals processes
• Proficiency in medical billing software and patient account management systems
• Excellent written and verbal communication skills
• Strong analytical and problem-solving skills
• Detail-oriented and highly organized
• Ability to work independently and meet deadlines

• High School Diploma or equivalent required;
  Associate or Bachelor's degree in healthcare administration, or the equivalent experience
• Minimum of 3 years of experience in medical appeals
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification is highly preferred.

• Health Insurance
• Vision Insurance
• Dental Insurance
• 401(k) plan with matching contributions