appeals specialist

Ensemble Health Partners

<div>Thank you for considering a career at Ensemble!
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country.
Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference!
O.N.E Purpose:<ul><li>
Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.</li><li>
Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.</li><li>
Striving for Excellence: Execute at a high level by demonstrating our &ldquo;Best in KLAS&rdquo; Ensemble Difference Principles and consistently delivering outstanding results.</li></ul>
The Opportunity:
CAREER OPPORTUNITY OFFERING:<ul><li>
Bonus Incentives</li><li>
Paid Certifications</li><li>
Tuition Reimbursement</li><li>
Comprehensive Benefits</li><li>
Career Advancement</li><li>
This position pays between $29.70 - $31.80 based on experience</li></ul>
The Acute Coding Appeals Specialist integrates medical coding principles and objectivity in the performance of coding appeals activities. Draws on ICD10CM, ICD10PCS, HCPCS, NCCI, CMS and CMG coding expertise and industry knowledge to substantiate coding principles to determine potential billing/coding issues, and quality concerns. Under indirect supervision, the Coding Appeals Specialist is responsible for reviewing and writing appeals for inpatient Diagnosis Related Group, (DRG) denials in order to support the assigned DRG and to address the clinical documentation utilized in the decision-making process to support the validity of the assigned codes.
Job Responsibilities:<ul><li>
The appeals professional integrates medical coding principles and objectivity in the performance of coding appeals/denials activities. Draws on ICD10CM, ICD10PCS, HCPCS, NCCI, CMS and CMG coding expertise and industry knowledge to substantiate coding principles to determine potential billing/coding issues, and quality concerns</li><li>
Participates in client system education to gain the knowledge necessary to appeal client accounts in ensuring that the coding is supported by the patient's clinical documentation, coding/cdi guidelines and other regulatory standards/guidelines as appropriate</li><li>
Maintain meticulous documentation, spreadsheets, account, and claim examples of root cause issues. Performs searches of governmental, payor-specific, hospital-specific, regulatory body, and literature rules, regulations, guidelines to identify and coding and billing requirements to make recommendations to client</li><li>
Assist in education and training for client coding companion as it relates to the outcomes of the coding appeals</li><li>
Meet established productivity standards for coding appeals &amp; coding certification requirement</li><li>
Attends in-house sessions to receive updated coding information and changes in coding and/or regulations</li><li>
Provides excellent customer service, in an organized and efficient manner, while maintaining a positive attitude</li></ul>
Required Experience:
<ul><li>Previous inpatient facility coding experience, working appeals, denials and edits</li><li>
5 years previous experience in coding, required</li><li>
Advanced knowledge of medical coding and billing systems, documentation, and regulatory requirements</li><li>
Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences.</li><li>
This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.</li></ul>
Minimum Education:<ul><li>
High School Diploma or GED</li></ul>
Required Certification:<ul><li>
Active Coding Certification (i.e. RHIA, RHIT, CCS, CIC, CPC, COC, etc.)</li></ul> 
#LI-HB1
#LI-REMOTE
Join an award-winning company
Five-time winner of &ldquo;Best in KLAS&rdquo; 2020-2022, 2024-2025
Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024
22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024
Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024
Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023
Energage Top Workplaces USA 2022-2024
Fortune Media Best Workplaces in Healthcare 2024
Monster Top Workplace for Remote Work 2024
Great Place to Work certified 2023-2024<ul><li>
Innovation</li><li>
Work-Life Flexibility</li><li>
Leadership</li><li>
Purpose + Values</li></ul>
Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:<ul><li>
Associate Benefits &ndash; We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.</li><li>
Our Culture &ndash; Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
</li><li>Growth &ndash; We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.</li><li>
Recognition &ndash; We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.</li></ul>
Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories.
Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact TA@ensemblehp.com.
This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role&rsquo;s range.
Employment Disclaimers &ndash; Ensemble</div>

Acute Coding Appeals Specialist

Pantherx Specialty Llc

<div>7,000 Diseases - 500 Treatments - 1 Rare Pharmacy
PANTHERx is the nation&rsquo;s largest rare disease pharmacy, and we put the patient experience at the top of everything that we do.
If you are looking for a career in the healthcare field that embraces authentic dedication to patient care, you don&rsquo;t need to look beyond PANTHERx. In every line of service, in every position and area of expertise, PANTHERx associates are driven to provide the highest quality outcomes for our patients.
We are seeking team members who:
Are inspired and compassionate problem solvers;
Produce high quality work;
Thrive in the excitement of the ever-challenging environment of modern medicine; and
Are committed to achieving superior health outcomes for people living with rare and devastating diseases.
At PANTHERx, we know our employees are the driving force in what we do. We cultivate talent and encourage growth within PANTHERx so that our associates can continue to explore their interests and expand their careers. Guided by our mission to provide uncompromising quality every day, we continue our strategic growth to further reach those affected by rare diseases.
Join the PANTHERx team, and define your own RxARE future in healthcare!
Location: Pittsburgh, PA; Hybrid 
Classification: Non-Exempt
Status: Full Time
Reports to: Manager, Clinical Programs
Purpose:
The Clinical Authorization and Appeals Specialist provides support and education to health care providers for prescribed treatment therapies. This role serves as a single point of contact for health care providers to coordinate alignment of documentation with prior authorization and appeals criteria. This role submits timely prior authorizations requests, appeals, initiatives to increase patient adherence, and closes collaboration with both internal and external stakeholders.
Responsibilities:<ul><li>
Educates health care providers regarding prior authorization and appeals criteria for prescribed therapies.</li><li>
Assesses clinical documentation provided and assist the health care provider with alignment to specific plan criteria.</li><li>
Creates initiatives to increase patient adherence and optimize patient care.</li><li>
Possess a broad and deep understanding of assigned disease states, products, and clinical programs.</li><li>
Closes collaboration with program team members as well as external stakeholders.</li><li>
Performs appropriate and accurate documentation of cases using call management software.</li><li>
Demonstrates appropriate judgment skills to be able to make independent clinical decisions.</li><li>
Fosters teamwork by trusting and supporting each other while encouraging collaboration at all levels of the organization. Embraces diversity and demonstrates the ability to work together.</li><li>
Provides superior customer service to internal and external clients, customers, and patients.</li><li>
Assumes accountability for own professional practice in achieving patient outcomes.</li><li>
Completes all other duties as assigned.</li></ul>
Required Qualifications:<ul><li>
Associate degree or bachelor&rsquo;s degree from an accredited nursing school as a Registered Nurse (RN).</li><li>
Must have demonstrated competence in community health or patient care setting, providing direct patient care with patients for 1-3 years.</li><li>
Strong writing and grammar skills.</li><li>
Strong organizational skills and a thorough knowledge of computers (Microsoft Office and Windows) are required.</li><li>
Demonstrated ability to work independently and meet goals.</li></ul>
Preferred Qualifications:<ul><li>
1-3 years of specialty pharmacy experience</li></ul>
Work Environment:
PANTHERx Rare Pharmacy offers flexibility only to eligible employees to work hybrid or remotely without compromising work performance, productivity, or team collaboration. This role routinely uses standard office equipment such as computers and phones.
Physical Demands:
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function of the job.
Benefits:
Hybrid, remote and flexible on-site work schedules are available, based on the position. PANTHERx Rare Pharmacy also affords an excellent benefit package, including but not limited to medical, dental, vision, health savings and flexible spending accounts, 401K with employer matching, employer-paid life insurance and short/long term disability coverage, and an Employee Assistance Program! Generous paid time off is also available to all full-time employees, as well as limited paid time off for part-time employees. Of course we offer paid holidays too!
Equal Opportunity:
PANTHERx Rare Pharmacy is an equal opportunity employer, and does not discriminate in recruiting, hiring, promotions or any term or condition of employment based on race, age, religion, gender, ethnicity, sexual orientation, gender identity, disability, protected veteran's status, or any other characteristic protected by federal, state or local laws.</div>

Clinical Authorization and Appeals Specialist

Lakeland Regional Health

<div><div><div><div><div>Position Details 
</div></div> 
<div><div>Lakeland Regional Health is a leading medical center located in Central Florida. With a legacy spanning over a century, we have been dedicated to serving our community with excellence in healthcare. As the only Provisional Level 1 Trauma center for Polk, Highlands, and Hardee counties, and the second busiest Emergency Department in the US, we are committed to providing high-quality care to our diverse patient population. Our facility is licensed for 910 beds and handles over 200,000 emergency room visits annually, along with 49,000 inpatient admissions, 21,000 surgical cases, 4,000 births, and 101,000 outpatient visits.
Active - Benefit Eligible and Accrues Time Off
Work Hours per Biweekly Pay Period: 80.00
 
Shift : Monday - Friday
 
Location : 210 South Florida Avenue Lakeland, FL - Remote after training
 
Pay Rate : Min $17.84 Mid $20.53
</div></div> 
<div><div>Position Summary 
</div></div> 
<div><div>Demonstrates commitment to the promises, vision, core purpose/mission and goals of LRMC, modeling the values and culture. Works under the supervision of the PFS Supervisor. The AR Follow and Denials Specialist is responsible for collecting payments for outstanding hospital claims, managing accounts, researching denials, submitting corrected claim requests, submitting appeals, and ensuring payments received are reconciled correctly with emphasis place on HIPAA compliance and in accordance with departmental goals, SOP&rsquo;s, and contract terms. Responsible for adhering to all Federal regulations and maintaining current knowledge of all Insurance guidelines. Escalates payer denials trends or claims issues to the PFS Leadership Team to address with the payer. Identifies trends, system issues, and potential process improvements to avoid future delays and denials. 
 
</div></div> 
<div><div>Position Responsibilities 
</div></div> 
<div><div>People At The Heart Of All We Do
<ul><li>Fosters an inclusive and engaged environment through teamwork and collaboration.
</li><li>Ensures patients and families have the best possible experiences across the continuum of care.
</li><li>Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created.
</li><li>Safety And Performance Improvement
<ul><li>Behaves in a mindful manner focused on self, patient, visitor, and team safety.
</li><li>Demonstrates accountability and commitment to quality work.
</li><li>Participates actively in process improvement and adoption of standard work.
</li><li>Stewardship
</li><li>Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities.
</li><li>Knows and adheres to organizational and department policies and procedures.
</li><li>Standard Work: AR Follow Up Denials Specialist
</li><li>Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives
</li><li>Responsible for all aspects of follow up and collections on accounts. This includes making outbound calls to payers and accessing payer websites.
</li><li>Collect payments for outstanding claims and ensure payments received are reconciled correctly.
</li><li>Confirm the claim expected reimbursement information to ensure claims are paid correctly. Follows department&rsquo;s process for follow up on underpayments/overpayments.
</li><li>Research and prepare responses for payor requests for additional information or documentation.
</li><li>Submits corrected claim rebill requests to the PFS Billing team when necessary to send to the insurance payer with correct information and ensures payment is received and claims are paid per contract
</li><li>Research denials and works with other departments such as Coding, Billing, CDM, UM, ect. to resolve denial.
</li><li>Submits the insurance reconsideration/appeals with supporting documentation in a timely manner and follow up with insurance to ensure receipt and processing. Follows insurance payer claims and appeals timely filing guidelines.
</li><li>Communicate clearly and professionally, in both written and verbal manners with internal personnel, payors, providers, patients, and other authorized representatives in regards to outstanding balances.
</li><li>Responsible for adequately working correspondence timely and efficiently (including EOBs, RA&rsquo;s, denial letters).
</li><li>Maintain knowledge of current government and carrier regulations, policies, manuals relevant to the industry.
</li><li>Identify and report trends in carrier payments and denials, which includes documentation of actions taken to resolve issues. Follows internal escalation process when necessary.
</li><li>Identify complex and aged claims issues and follows internal escalation process appropriately.
</li><li>Maintain patient confidentiality and privacy; adheres to HIPAA standards.
</li><li>Organizes job functions and work assignments to be able to effectively complete assignments within established time frames.
</li><li>Must meet department Productivity Guidelines. Works with all areas of the department to assure maximum productivity. Utilizes the PFS Productivity tracker.
</li><li>Demonstrates knowledge of all equipment and systems/technology necessary to complete duties and responsibilities.
</li><li>Other duties, responsibilities, and activities may change or be assigned at any time with or without notice.
</li></ul></li></ul></div></div> 
<div><div>Competencies &amp; Skills 
</div></div> 
<div><div>Essential: 
 
<ul><li>Four years general Patient Accounting experience including understanding of Managed Care contracts and claims analysis. Understanding of Medicaid, Medicaid Manage Care, Medicare, Medicare Advantage plans, Commercial, Liability, and Workers' Compensation payers and their guidelines. Knowledge of healthcare rules and regulations.
</li><li>An overall understanding of the appeals processes through completion.
</li><li>Ability to read/interpret EOB&rsquo;s
</li><li>Working knowledge of Word, Excel or other Microsoft applications. Good analytical skills for problem solving, typing of 40 WPM and data entry.
</li><li>Knowledge of Accounting Principles; analytical mathematical skills, professional customer service communication skills.
</li><li>Demonstrates accuracy and thoroughness; Meets productivity standards; Completes work in timely manner.
</li><li>Consistently shows ability to recognize and deal with priorities. Adapts to changes in the work environment; Able to deal with frequent change, delays, or unexpected events.
</li><li>Knowledge of HIPAA guidelines.
</li><li>Demonstrates good judgment and reasoning when investigating and solving problems. Good critical thinking skills.
</li><li>Ability to prioritize and manage time effectively.
</li></ul>Nonessential:
<ul><li>Ability to prioritize and manage time effectively.
</li></ul></div></div> 
<div><div>Qualifications &amp; Experience 
</div></div> 
<div><div>Essential:
<ul><li>High School or Equivalent
</li></ul>Nonessential:
<ul><li>Associate Degree
 </li></ul>Nonessential:
<ul><li>Business or Healthcare Administration
 </li></ul>Other information:
<div>Experience Essential:
 
<ul><li>Two years general patient accounting experience. Experience working with and general understanding of Medicaid, Medicaid Manage Care, Medicare, Medicare Advantage plans, Commercial, Liability, and Workers' Compensation payors.
</li></ul> 
Experience Preferred:
 
<ul><li>Four years general patient accounting experience. Experience working with and general understanding of Medicaid, Medicaid Manage Care, Medicare, Medicare Advantage plans, Commercial, Liability, and Workers' Compensation payors.
</li></ul> 
Certifications Preferred:
 
<ul><li>AAHAM or HFMA certification</li></ul></div></div></div></div></div></div>

AR Follow Up Denials Specialist - Denial & Appeals Mgmt

Tanaq Health

<div>
 
 Description
 
 
 
 
 Overview
 
 
 
 Tanaq Support Services (TSS) delivers professional, scientific, and technical services and information technology (IT) solutions to federal agencies in health, agriculture, technology, and other government services. TSS is a subsidiary of the St. George Tanaq Corporation, an Alaskan Native Corporation (ANC) committed to serving Federal customers while also giving back to the Tanaq native community and shareholders.
 
 
 
 About The Role
 
 
 
 We are seeking a
 
 Clinical Appeals Reviewer
 
 to support a contract with our federal client. The Clinical Appeals Professional performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Qualified candidates must be licensed health care professionals capable of rendering independent clinical judgment, including but not limited to Registered Nurses (RN), Physical Therapists (PT), Occupational Therapists (OT), and Respiratory Therapists (RT).
 
 
 This is a remote position that can be based anywhere in the United States. Must be able to work on a rotating schedule on weekends and holidays.
 
 
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
 </li>
 <li>
 Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
 </li>
 <li>
 Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
 </li>
 <li>
 Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
 </li>
 <li>
 Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
 </li>
 <li>
 Stays abreast of changes in regulations, medical and healthcare practices, policies, and procedures.
 </li>
 <li>
 Participates in case-specific verbal discussions.
 </li>
 <li>
 Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
 </li>
 <li>
 Plans responses to statistical analysis challenges with assistance from statisticians.
 </li>
 <li>
 Attends meetings and participates in workgroups at management's direction.
 </li>
 <li>
 Conducts quality reviews, as needed.
 </li>
 <li>
 Serves as a subject matter expert.
 </li>
 <li>
 Mentors and/or trains staff.
 </li>
 <li>
 May conduct quality reviews and audits.
 </li>
 <li>
 Participates in special projects and performs other duties as assigned.
 
 
 </li>
 </ul>
 
 Requirements
 
 
 
 
 Required Skills and Experience
 
 
 
 <ul>
 <li>
 Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
 </li>
 <li>
 Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
 </li>
 <li>
 Demonstrated experience writing or making medical necessity decisions.
 </li>
 <li>
 Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
 </li>
 <li>
 Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
 </li>
 <li>
 Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
 </li>
 <li>
 Prioritize and organize work tasks to handle multitasking and meet deadlines.
 </li>
 <li>
 Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
 </li>
 <li>
 Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
 </li>
 <li>
 Experience in making decisions that support business objectives and goals.
 </li>
 <li>
 Ability to identify and resolve problems or refer issues appropriately.
 </li>
 <li>
 Communicate effectively verbally and in writing.
 </li>
 <li>
 Adapt to the needs of internal and external customers.
 </li>
 <li>
 Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
 </li>
 <li>
 Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
 </li>
 <li>
 Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred.
 </li>
 <li>
 Must have resided in the United States for a minimum of three (3) years out of the last five (5) years. This is a contractual requirement.
 </li>
 <li>
 Must possess a valid driver's license with a clear and satisfactory driving record.
 </li>
 <li>
 Ability to obtain and maintain public trust clearance and customer approval.
 </li>
 <li>
 Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.
 
 
 </li>
 </ul>
 
 Education and Training
 
 
 
 <ul>
 <li>
 Associate's degree or 60 or more credit hours towards a Bachelor&rsquo;s degree from an accredited college or university in healthcare or related discipline.
 </li>
 <li>
 Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for an Associate&rsquo;s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)
 
 
 </li>
 </ul>
 
 Physical Requirements And Work Environment
 
 
 
 <ul>
 <li>
 Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching.
 </li>
 <li>
 Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.
 </li>
 <li>
 May require the ability to operate a motor vehicle and travel by motor vehicle and commercial airline. May require overnight travel. Travel may be less than 5% annually.
 
 
 </li>
 </ul>
 
 Who We Are
 
 
 
 Tanaq Management Services (TMS) is a public health contractor, certified 8(a) business, owned by St. George Tanaq Corporation, an Alaska Native Corporation. (ANC). We listen to our stakeholders and leverage our science, technology, communication, and program expertise to understand and provide feedback as we develop solutions.
 
 
 
 Our Commitment to Non-Discrimination
 
 
 
 Tanaq is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, status as a protected veteran or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-free Workplace Act of 1988 and E-Verify.
 
 
 If you are an individual with a disability and need assistance completing any part of the application process, please email accommodation@tanaq.com to request a reasonable accommodation. This email is for accommodation requests only and cannot be used to inquire about the status of applications.
 
 
 
 Notice on Candidate AI Usage
 
 
 
 Tanaq is committed to ensuring a fair and competitive interview process for all candidates based on their experience, skills and education. To ensure the integrity of the interview process, the use of artificial intelligence (AI) tools to generate or assist with responses during phone, in person and virtual interviews is not allowed. However, candidates who require a reasonable accommodation that may involve AI are required to contact us prior to their interview at accommodation@tanaq.com.
 
 
 
 To Apply For This Positions, Visit
 
 
 
 https://recruiting.paylocity.com/Recruiting/Jobs/Details/4071254
</div>

Clinical Appeals Reviewer (Licensed Healthcare Professional)

Prisma Health

<div>Inspire health. Serve with compassion. Be the difference.
Job Summary
Performs tasks of moderate to difficult complexity relating to both hospital and physician accounts. Handles a large volume of inbound calls. Responsible for also making outbound calls related to self-pay follow up on accounts. Assists patients with requests for information, complaints, and resolving issues. Responsible for data analysis and interpretation throughout all functions of revenue cycle, to determine reasons for denials, non-payment and overpayment, post/balance/correct electronic remittances, billing and follow-up of government payers and specialized accounts, analysis/correction of correct coding guidelines, preparation of accounts for appeal, review/analysis of insurance credit balances and analysis/movement of unapplied, unidentified, undistributed balances. Moderate to difficult levels of evaluation, analysis, decision making required in these roles.
Essential Functions<ul><li>
All team members are expected to be knowledgeable and compliant with Prisma Health's values: Inspire health. Serve with compassion. Be the difference.</li><li>
Resolves billing concerns, addresses inquiries related to insurance concerns/matters, assist patients with MyChart while simultaneously establishing a rapport with our diverse field of patients. Reviews accounts to determine insurance coverage; obtains and corrects any missing or inaccurate information. Discusses patient responsibility, which includes educating patients on claim processing, deductible, coinsurance, and co-pays. Interacts with patients by making patients aware of payment options such as payment plans and financial assistance as well as how to apply for financial assistance if circumstance warrant. Ability to set up payment plans in MyChart based on patient's personal needs.
</li><li>Greets patients in a professional and courteous manner. Communicates clearly and professionally in both oral and written communication. Be clear and concise in all communication to ensure patients understand the information that is being communicated to them by the Customer Service Specialist. Maintains a high level of poise and professionalism in dealing with patients. Knows when to escalate a patient service issue real time. Research customer requests or issues, determines if further action is needed, forwards to appropriate party for resolution, and exercises good judgement to determine urgency of patient's need.
</li><li>Contacts payer and makes hard inquiries on account status if needed. Escalates problem accounts to the appropriate area(s). Documents billing activity on a patient's accounts according to departmental guidelines; ensures compliance with all applicable billing regulations and reports any suspected compliance issues to departmental leaders. Properly documents accounts clearly with indicators and activities so that tracking and trending can be prepared for any potential further analysis if needed.
</li><li>Ensures all work is compliant with privacy, HIPAA, and regulatory requirements.</li><li>
Participates in general or special assignments and attends all required training. Adheres to policies and procedures as required by Prisma Health and follows all compliant regulatory payer guidance.
</li><li>Answers all incoming calls from Prisma Health patients
</li><li>Performs other duties as assigned.</li></ul>
Supervisory/Management Responsibilities<ul><li>
This is a non-management job that will report to a supervisor, manager, director or executive.</li></ul>
Minimum Requirements<ul><li>
Education - High School diploma or equivalent OR post-high school diploma / highest degree earned</li><li>
Experience - Two (2) years billing, bookkeeping, and/or accounting experience</li></ul> 
In Lieu Of<ul><li>
NA</li></ul>
Required Certifications, Registrations, Licenses<ul><li>
NA</li></ul> 
Knowledge, Skills and Abilities<ul><li>
Knowledgeable of the job functions required for a A/R Follow-up Representative, Cash Posting Representative, Claims Clearinghouse Representative, Correspondence Representative, Credit Processing Specialist, Denial/Appeals Specialist, Payment Research Specialist and a Quality Assurance Specialist.
</li><li>Knowledgeable of the entire Revenue Cycle and Epic.</li></ul>
Work Shift
Day (United States of America)
Location
Patewood Outpt Ctr/Med Offices
Facility
7001 Corporate
Department
70019935 System Billing Office
Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.</div>

Single Billing Office Customer Service Representative, FT, Days, - Remote

Elevance Health

<div>
 
 Nurse Appeals- Licensed Nurse
 
 
 
 
 Location:
 
 Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
 
 
 Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
 
 
 
 Hours
 
 : The work schedule for this position is Tuesday through Saturday with Sunday rotation. Business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8-hour shift between those hours, including holidays on a rotational basis.
 
 
 The
 
 Nurse Appeals
 
 is responsible for investigating and processing and medical necessity appeals requests from members and providers.
 
 
 
 How You Will Make An Impact
 
 
 
 <ul>
 <li>
 Conducts investigations and reviews of member and provider medical necessity appeals.
 </li>
 <li>
 Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
 </li>
 <li>
 Extrapolates and summarizes medical information for medical director, consultants and other external review.
 </li>
 <li>
 Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
 </li>
 <li>
 Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
 </li>
 <li>
 Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
 </li>
 <li>
 Generates written correspondence to providers, members, and regulatory entities.
 </li>
 <li>
 Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.
 
 
 </li>
 </ul>
 
 Minimum Requirements
 
 
 
 <ul>
 <li>
 Requires a HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
 
 
 </li>
 </ul>
 
 Preferred Skills, Capabilities And Experiences
 
 
 
 <ul>
 <li>
 AS or BS in Nursing preferred.
 </li>
 <li>
 Three to five years of clinical experience as a Registered Nurse strongly preferred.
 </li>
 <li>
 Have a current active unrestricted RN license to practice nursing within the scope of licensure in applicable state(s) or territory of the United States strongly preferred.
 </li>
 <li>
 Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred.
 </li>
 <li>
 Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred.
 </li>
 <li>
 Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred.
 </li>
 <li>
 Experience with Facets, Macess, and ACMP is preferred.
 
 
 </li>
 </ul>
 For candidates working in person or virtually in the below locations, the salary* range for this specific position is $72,492 to $108,738
 
 
 
 Locations: Latham, New York
 
 
 
 In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
 
 
 <ul>
 <li>
 The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company&rsquo;s sole discretion, consistent with the law.
 
 
 </li>
 </ul>
 Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
 
 
 Who We Are
 
 
 Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
 
 
 How We Work
 
 
 At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
 
 
 We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
 
 
 Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
 
 
 The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
 
 
 Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
 
 
 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
</div>

Nurse Appeals

Alignment Healthcare

<div>Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
This position is remote in Orange, CA. 
 
The Appeals &amp; Grievance Coordinator is responsible for the day-to-day functions of the tracking and trending of all grievances, appeals, and complaints received within the Member Services Department. Acts as the primary investigator and contact person for member and provider grievances and appeals.
GENERAL DUTIES/RESPONSIBILITIES : 
1. Acknowledges the receipt of all grievance/appeals, and CTM (Complaint Tracking Module). 
2. Gathers pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determines the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifies the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue. 
3. Composes written correspondence to members in accordance to plan policy and CMS Guidelines. 
4. Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal. 
5. Thoroughly documents all action taken on behalf of the member or provider to resolve the grievance/appeal. 
6. Ensures that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy. 
7. Prepares case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate. 
8. Prepares clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors). 
9. Maintains accurate and timely documentation, including complete files of all grievances/appeals. Prepares monthly and quarterly reports as requested. 
10. Identifies training opportunities and potential system and process improvements relating to grievance/appeal data. 
11. Participates in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews. 
12. Other duties as assigned.
Job Requirements:
Experience:<ul><li>Required: Two years&rsquo; experience in data entry and general office background.</li></ul>
Three years of customer service experience. Minimum 1 year Member Services or similar experience.<ul><li>Preferred: 2 years healthcare or insurance experience in a senior setting.</li></ul>
Education:<ul><li>Required: High School Diploma or GED.</li><li>Preferred: Associate degree (A.A.) degree.</li></ul>
Training:<ul><li>Required:</li><li>Preferred:</li></ul>
Specialized Skills:<ul><li>Required:</li></ul><ul><li>
Knowledge of MediCal and Medicare Managed Care Plans.</li><li>
Ability to Keyboard/Type 40+ words per minute and use the 10-key by touch.</li><li>
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.</li><li>
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;</li><li>
Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.</li><li>
Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10&rsquo;s and 100&rsquo;s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.</li><li>
Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>Preferred: Bi-lingual (English/Spanish)</li></ul>
Licensure:<ul><li>Required: None</li></ul>
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1 While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
2 The employee is frequently required to walk; stand; reach with hands and arms.
3 The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
4 The employee must occasionally lift and/or move up to 20 pounds.
5 Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Pay Range: $44,790.00 - $67,185.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.<ul><li>DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Appeals & Grievances Coordinator - Remote - Orange, CA

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