We are seeking and experienced Claims Appeals Specialist.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
In accordance with State and Federal laws, identifies, investigates and resolves claims under review, returned, disputed, or denied by either a commercial or a government payer (e.g. Blue Cross Blue Shield or Medicare).
Performs detailed review and analysis to investigate audit requests from Medicare Recovery Audit Contractors. Determines why a claim is under review, in dispute, or was denied. Coordinates with various internal departments ensuring all appropriate documentation is obtained in order to respond to audit requests appropriately.
Ensures all requests for patient information meets applicable HIPAA requirements before information is shared.
Requests copies of the medical records and corresponding claims.
Analyzes information obtained to identify discrepancies and anomalies determining if services were properly documented and properly billed.
Documents any findings resulting from the claim review and determines if a remedy is available to address the finding. If a remedy is appropriate, works with client to implement remedy according to all applicable external requirements and internal policies.
Ensures necessary repayments are completed by the appropriate party for any identified payment discrepancies.
Interprets and understands health insurance appeals and provider dispute resolution processes, applicable clinical guidelines, and health payer coverage policies in order to effectively prepare claim packages nt procedures are followed.
Maintains current knowledge of operational and billing policies, practices, and references
Responds to inquiries and/or reports of billing concerns, noncompliance with company policy and procedure taking the appropriate actions as required.