appeals specialist

Amerit Consulting

<div>
 
 
 
 OVERVIEW:
 
 
 
 
 
 Our client, a US Fortune 50 organization and a leading provider of Healthcare and Health Insurance services
 
 , seeks an accomplished
 
 Medical Appeals Specialist
 
 .
 
 
 
 
 
 
 
 IMPORTANT NOTES: REMOTE / WORK-FROM-HOME RELATED:
 
 
 
 <ul>
 <li>
 
 This will be a Remote role.
 
 </li>
 <li>
 
 Estimated dates: 05/18/2026 start; likely to extend and/or convert temp-hire after the temp work is completed
 
 </li>
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 Equipment's will be provided.
 
 </li>
 <li>
 MUST have high-speed wired Internet connection. Wi-Fi / Wireless connections are not allowed.
 </li>
 <li>
 MUST have a reliable home-office environment.
 </li>
 <li>
 
 Training Shift Hours: 40 hours per week | 08:00am to 4:30pm (Eastern Time).
 
 </li>
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 Training will be 5-6 weeks.
 
 </li>
 <li>
 
 POST training, the candidates may choose to flex start time of 6:00 AM to 10:00 AM (Eastern Time).
 
 </li>
 <li>
 
 These are not HYBRID requirements while working temp. However, if/when they convert temp-hire, they must be willing to work onsite depending on what the HYBRID requirements for FTE associates are at the time of conversion (usually 1-3 days per week)
 
 </li>
 <li>
 No overtime, weekends, or on-call requirements
 </li>
 </ul>
 
 
 
 
 
 
 Client will be considering candidates MUST sit within 50 miles of below location (Please apply accordingly):
 
 
 
 <ul>
 <li>
 New York, NY
 </li>
 <li>
 Iselin, NJ
 </li>
 <li>
 Morristown, NJ
 </li>
 <li>
 Lake Success, NY
 </li>
 <li>
 Ashburn, VA
 </li>
 <li>
 Seattle, WA
 </li>
 </ul>
 
 
 
 
 
 
 Responsibilities:
 
 
 
 <ul>
 <li>
 This is an entry level position in the NGS Appeals Department that reviews, analyzes and
 
 processes non-complex pre-service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (Part A &amp; B)
 
 related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
 </li>
 <li>
 Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
 </li>
 <li>
 Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
 </li>
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 The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements.
 </li>
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 As such, the analyst will strictly follow department guidelines and tools to conduct their reviews.
 </li>
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 Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
 </li>
 <li>
 Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
 </li>
 <li>
 The analyst may serve as a liaison between grievances &amp; appeals and /or medical management, legal, and/or service operations and other internal departments.
 </li>
 </ul>
 
 
 
 
 
 
 Required Qualifications:
 
 
 
 <ul>
 <li>
 
 Must have High School Diploma or GED.
 
 </li>
 <li>
 
 Must have 3-4 years&rsquo; experience working with Medical Claims, grievances and appeals, Medicare, Part A OR PART B.
 
 </li>
 <li>
 
 Familiarity with medical terminology, demonstrated business writing proficiency.
 
 </li>
 <li>
 Must have strong understanding of provider networks, the
 
 medical management process
 
 ,
 
 claims processing
 
 .
 </li>
 <li>
 Must be proficient handling
 
 high volume
 
 
 inbound calls
 
 .
 </li>
 <li>
 Must have background in
 
 following up with insurance providers
 
 .
 </li>
 </ul>
 
 
 
 
 
 
 I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.
 
 
 
 
 
 
 
 
 
 
 
 Recruiter Contact Info
 
 
 
 Jatin Rattan
 
 
 E-mail: jatin.rattan@ameritconsulting.com
 
 
 www.ameritconsulting.com
 
 
 
 
 
 
 I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.
 
 
 
 
 
 
 
 Company Overview:
 
 
 
 Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally; as well as small to mid-sized organizations on a local &amp; regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients&rsquo; businesses forward.
 
 
 
 
 
 Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
 
 
 
 
 
 This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws.
 
</div>

Medical Appeals Specialist

Corporate Transportation Group

<div>NEMT Grievances &amp; Appeals Specialist 
 Reports To: Quality Assurance Manager 
 Location: Remote or Denver, Colorado 
 FLSA Status: Non-Exempt 
Position Overview 
 The Grievances &amp; Appeals Specialist is responsible for managing, investigating, and resolving member complaints, grievances, and appeals in compliance with client, state, and federal requirements. Reporting to the Quality Assurance Manager, this role plays a critical part in protecting member rights, identifying service gaps, and driving continuous quality improvement across MediDrive&rsquo;s operations.
The Specialist ensures all cases are handled timely, accurately, and in accordance with contractual turnaround times, while maintaining a strong focus on member advocacy, regulatory compliance, and service excellence.
Key Responsibilities<ul><li>
Case Management &amp; Investigation 
 Receive, log, and acknowledge grievances and appeals from members, providers, clients, and regulatory agencies.</li><li>
Conduct thorough investigations by collecting trip records, call recordings, provider documentation, GPS data, and relevant system notes.</li><li>
Analyze root causes of service failures and recommend corrective and preventive actions.</li><li>
Draft clear, compliant written responses to members and clients within required turnaround timeframes.</li><li>
Escalate urgent or high-risk matters to the Quality Assurance Manager and leadership as appropriate.</li></ul>
Compliance &amp; Reporting<ul><li>
Ensure all grievances and appeals are processed in accordance with Medicaid, Medicare Advantage, and client-specific contractual requirements.</li><li>
Monitor and track turnaround time compliance to avoid penalties or liquidated damages.</li><li>
Maintain accurate documentation within the Grievance &amp; Appeals tracking system.</li><li>
Assist with internal audits, client audits, and regulatory reviews related to complaint resolution.</li><li>
Identify trends and provide reporting to support performance improvement initiatives.</li></ul>
Collaboration &amp; Resolution<ul><li>
Partner with Operations, Network Development, Call Center, and Technology teams to resolve issues and implement sustainable solutions.</li><li>
Engage with transportation providers (TPs) to gather documentation and ensure corrective actions are completed.</li><li>
Coordinate with clients, government agencies, and legal/compliance departments when cases fall outside standard workflows.</li><li>
Monitor member trips when necessary to ensure real-time issue resolution and service recovery.</li></ul>
Continuous Quality Improvement<ul><li>
Identify systemic issues impacting member experience and escalate patterns to leadership.</li><li>
Support quality improvement initiatives and contribute to policy and procedure enhancements.</li><li>
Participate in special projects and additional duties as assigned by the Quality Assurance Manager.</li></ul>
Qualifications
Education &amp; Experience<ul><li>
High school diploma required; Associate or Bachelor&rsquo;s degree preferred.</li><li>
Minimum of two (2) years of experience in grievance resolution, customer service, healthcare operations, NEMT, or managed care.</li><li>
Experience working in Medicaid or Medicare Advantage environments preferred.</li></ul>
Skills &amp; Competencies<ul><li>
Strong knowledge of complaint resolution processes and regulatory turnaround requirements.</li><li>
Excellent written and verbal communication skills, including professional phone etiquette.</li><li>
Strong analytical and problem-solving abilities with attention to detail.</li><li>
Ability to manage a high volume of cases in a fast-paced environment.</li><li>
Proficiency in Microsoft Office Suite (Word, Excel, Outlook).</li><li>
Typing speed of 35+ words per minute with high accuracy.</li><li>
Ability to learn and navigate multiple systems efficiently.</li><li>
Ability to work independently while collaborating effectively within a cross-functional team environment.</li><li>
Medical front-office, case management, social work, or healthcare administrative experience preferred.</li><li>
Bilingual (English/Spanish or other languages) preferred.</li></ul>
 MediDrive is an equal opportunity employer committed to providing reliable, compliant, and member-centered Non-Emergency Medical Transportation services.</div>

NEMT Grievances & 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

Macrise Tech Solutions

Job Description: Accounts Receivable &amp; Denial Management<ul><li>Monitor and manage outstanding insurance claims to support the reduction of overall Accounts Receivable (AR) balances.</li><li>Conduct regular follow-ups on denied claims to ensure timely resolution and maximize claim recovery.</li><li>Analyze Electronic Remittance Advice (ERA) reports to identify recurring denial trends and recommend corrective measures.</li><li>Prepare, submit, and track appeals for denied or underpaid claims, ensuring all supporting documentation is accurate and complete.</li><li>Investigate payment discrepancies and escalate complex or unresolved issues to the Billing Manager as needed.</li><li>Maintain up-to-date AR aging reports and provide consistent weekly and monthly performance updates.</li><li>Manage billing and claims processing for specialized services, including TMS, Spravato, and psychological assessments.</li><li>Collaborate with the Billing Manager to achieve AR reduction, recovery, and accuracy targets.</li></ul>Patient &amp; Provider Communication<ul><li>Respond promptly and professionally to billing-related inquiries from patients, providers, and internal teams.</li><li>Review and validate patient account information prior to initiating collections or claim follow-ups.</li><li>Work closely with providers to resolve claim issues, including coding discrepancies and missing documentation.</li><li>Communicate with insurance payers regarding eligibility, prior authorizations, and network participation.</li><li>Address patient concerns with professionalism and empathy, including processing refunds when appropriate.</li></ul>Systems Management &amp; Process Improvement<ul><li>Create, monitor, and resolve billing-related support tickets within the eClinicalWorks (eCW) system.</li><li>Provide guidance and support to team members on AR follow-up strategies and denial resolution processes.</li><li>Coordinate with U.S.-based billing teams to ensure accurate and timely claim submissions.</li><li>Participate in operational meetings to review performance trends and recommend process improvements.</li><li>Stay informed on payer policies, regulatory requirements, and industry best practices in medical billing and reimbursement.</li></ul>Job Type: Full-timePay: Rs45,000.00 - Rs70,000.00 per monthAbility to commute/relocate:<ul><li>Wapda Town: Reliably commute or planning to relocate before starting work (Required)</li></ul>Application Question(s):<ul><li>Willing to work the night shift in Wapda Town, Lahore?</li></ul>Experience:<ul><li>AR: 1 year (Preferred)</li></ul>Language:<ul><li>English (Required)</li></ul>Work Location: In person

Medical Billing Denials & 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
 
 
 
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 Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
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 Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
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 Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
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 Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
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 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.
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 Stays abreast of changes in regulations, medical and healthcare practices, policies, and procedures.
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 Participates in case-specific verbal discussions.
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 Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
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 Plans responses to statistical analysis challenges with assistance from statisticians.
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 Attends meetings and participates in workgroups at management's direction.
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 Conducts quality reviews, as needed.
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 Serves as a subject matter expert.
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 Mentors and/or trains staff.
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 May conduct quality reviews and audits.
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 Participates in special projects and performs other duties as assigned.
 
 
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 Requirements
 
 
 
 
 Required Skills and Experience
 
 
 
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 Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
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 Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
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 Demonstrated experience writing or making medical necessity decisions.
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 Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
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 Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
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 Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
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 Prioritize and organize work tasks to handle multitasking and meet deadlines.
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 Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
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 Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
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 Experience in making decisions that support business objectives and goals.
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 Ability to identify and resolve problems or refer issues appropriately.
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 Communicate effectively verbally and in writing.
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 Adapt to the needs of internal and external customers.
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 Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
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 Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
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 Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred.
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 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.
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 Must possess a valid driver's license with a clear and satisfactory driving record.
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 Ability to obtain and maintain public trust clearance and customer approval.
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 Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.
 
 
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 Education and Training
 
 
 
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 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.
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 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.)
 
 
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 Physical Requirements And Work Environment
 
 
 
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 Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching.
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 Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.
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 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.
 
 
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 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
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Clinical Appeals Reviewer (Licensed Healthcare Professional)

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