Appeals Specialist

Position Summary

At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews. 

The Appeals Specialist I is responsible for performing triage, review, analysis, and resolution of facility-submitted appeals, involving non-clinical appeals, and clinical appeals where no new clinical information is received for review. The role focuses on payment, reimbursement, and administrative determinations. Ensuring appeals are processed accurately, thorough, timely and in compliance with client and organization requirements.   

Responsibilities 

This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of the department and MedReview in general. 

• Triage admin appeals to validate appropriateness for review and workflow to follow. Route appeals appropriately when new information is received that’d warrant a clinical review   

• Process non-clinical facility appeals including payment disputes, reimbursement amounts, contract interpretation, processing errors. Analyze payment history, contracts, in client(s) applications  

• Process clinical appeals when no new clinical information is submitted 

• Determine appeal decisions in accordance with existing policies from client and/or organization  

• Provide clear, thorough, and accurate appeal responses  

• Coordinate and communicate with Clinical Review teams when new clinical information is received or when escalation is required  

• Communicate with various stakeholders to bring forth emergent matters or trends  

Qualifications 

• Associate degree (healthcare field preferred) or an equivalent combination of education, and relevant work experience  

• 1 year experience working in healthcare claims, appeals, billing or revenue cycle  

• Experience in handling administrative review of clinical appeals  

• Strong professional judgement and escalation awareness with the ability to analyze case details to make timely and sound decisions  

• Ability to quickly learn and navigate new systems and platforms 

• Basic understanding of claims adjudication process and terms  

• Excellent written and verbal communication skills for effective interaction with diverse stakeholders 

• Ability to manage tasks, and prioritize work in an effective way  

• High attention to detail and document accuracy 

• Proficiency in MS Office applications (Outlook, Excel, Word) 

• Must be able to multitask, manage high volume case load, and work in a challenging environment to meet strict time sensitive deadlines 

• Ability to work independently  

• Must show patience and the ability to remain calm under pressure in an atmosphere of frequent interruptions 

Remote Work Requirements 

• High speed internet (100 Mbps per person recommended) with secured WIFI.  

• A dedicated workspace with minimal interruptions to protect PHI and HIPAA information. 

• Must be able to sit and use a computer keyboard for extended periods of time.