Where compassion meets innovation and technology and our employees are family.

G ENERAL P URPOSE OF J OB :

The Claims and Appeals Specialist II is a certified medical coder that performs audits for correct coding and claims payments and oversees the claims appeal process for provider and member appeals. This position also investigates Coordination of Benefit (COB) claims. The Claims and Appeals Specialist II reports to the Director of Claims Oversight.

E SSENTIAL D UTIES AND R ESPONSIBILITIES :

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive;
employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.

General Duties:

• Maintains the utmost level of confidentiality at all times.
• Adheres to hospital and DHP policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Performs other duties as requested.
• Claims and Appeals Specialist II Duties and Responsibilities:
• Reviews claims appeal and makes recommendations regarding reprocessing/denial of payment.
• Research provider’s claims questions.
• Works closely with Provider Relations Representatives to assist with provider claim issues.
• Provides incite to potential claims payment issues.
• Notifies Compliance Officer for DHP of potential fraud and abuse.
• Research billing issues.
• Responds to providers regarding claims-related issues.
• coordination of benefit activities.
• Coordinates re-consideration of claims with DHP’s Third Party Claims Administrator
• Active member of bi-weekly claims meetings between DHP and DHP’s Third Party Claims Administrator.

E DUCATION AND / OR E XPERIENCE :

High school diploma or general education degree (GED); or associate’s degree (A. A.) or equivalent from two-year college or technical school; three to five years related experience and/or training; or equivalent combination of education and experience.
3 -5 years’ experience of coding in an acute care hospital setting preferred