Medical Appeals Specialist

Houston, TX

Posted: 09/14/2018 Employment Type: Contractor Industry: Health Care, Admin - Clerical Job Number: JD76BS6987NBGNFMKLD

Pulse Staffing is currently seeking an experienced appeals specialist for a long term temporary work-from-home position with one of our busy clients. This position has the potential to become a permanent role for an excellent candidate.

General responsibilities include:

  • Provide effective collaboration as the liaison between the reimbursement team, surgeons/surgeon s offices and patients to coordinate attempts to secure coverage
  • Provide high quality customer service and frequent interaction with surgeon offices and patients regarding case status and outcome of pre-authorizations and appeals in company s case management program
  • Support the company s strategic reimbursement plans, e.g., case management and reimbursement policy efforts
  • Must at all times act and conduct company business in an honest, ethical and strictly legal manner, complying with the Code of Conduct, other company policies, the AdvaMed Code and all applicable laws and regulations, whether national, regional, state or local
  • Encouraged, expected and required to report any suspected violations of laws, regulations, the Code or any other Company policy, and all other suspected unethical behavior

Specific Responsibilities are:

  • Communicate with patient s insurance coverage to determine process for pre-authorizations/pre-determinations through all levels of appeals; manage the insurance authorization process, including the verification of benefits, prior authorization process, and the appeal process
  • Coordinate securing patient s supporting medical documentation, letters of medical necessity and appeal letter signatures from referring surgeons
  • Guide patients through the insurance coverage support process; communicate regularly with patients and their families about case status and next steps in the appeal process, and address patient concerns.
  • Coordinate case authorization and appeal strategies with Area Reimbursement Manager
  • Provide Territory Manager or other sales management personnel with case updates, as needed
  • Track, monitor and report the outcomes of reimbursement initiatives (e.g., appeal outcomes from peer-to-peer reviews, external [independent] medical review, trends observed from the various initiatives, etc.) in assigned territory
  • Maintain accurate and complete documentation of all inquiries
  • Other duties as assigned

High School diploma/GED Required.

Associates degree or higher preferred.

At least 3-5 years of recent experience working with insurance denials and appeals

Excellent customer service and communication skills.

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