Appeals Specialist

Job SummaryThe Appeals Specialist is responsible for reviewing insurance denials and preparing comprehensive appeal submissions for behavioral health, substance use disorder, primary care, and ancillary services. This position serves as a liaison between clinical staff, billing, compliance, and insurance payers to maximize reimbursement through timely and well-supported appeals. The specialist analyzes denial trends, researches payer policies, prepares appeal packets, coordinates peer-to-peer reviews, and ensures all appeal activities comply with payer requirements and regulatory standards.Essential FunctionsEssential functions are duties that are essential or primary to the position or the reason the position exists. An individual must be able to perform the essential functions of the position with or without reasonable accommodation.The Appeals Specialist performs an integral role in carrying out the mission of The Counseling Center, Inc., by performing the following duties:Appeals ManagementReview denied claims and authorization decisions to identify the reason for denial.Analyze payer policies, provider manuals, medical necessity criteria, and applicable federal and state regulations.Prepare first-level, second-level, expedited, and external appeal submissions.Draft clear, concise, and evidence-based appeal letters using clinical documentation and payer-specific guidelines.Coordinate peer-to-peer reviews between providers and payer medical directors when appropriate.Monitor appeal filing deadlines and ensure timely submission of all appeal documentation.Track appeal outcomes and communicate decisions to appropriate clinical, billing, and leadership staff.Maintain organized records of all appeal activity and supporting documentation.Escalate recurring denial trends and reimbursement concerns to leadership.Revenue IntegrityCollaborate with billing, compliance, utilization management, and clinical teams to reduce preventable denials.Review denial reports to identify patterns, root causes, and opportunities for process improvement.Recommend corrective actions to improve documentation, coding, and billing practices.Assist with payer audits and provide supporting documentation related to appealed claims.Participate in denial prevention initiatives by educating staff on common denial reasons and payer expectations.Documentation & ReportingMaintain accurate records of appeal submissions, correspondence, and payer determinations.Document all payer communications within the electronic health record or designated tracking system.Generate reports related to:Appeal volumeAppeal turnaround timesAppeal success ratesDenial trendsOutstanding appealsFinancial recovery resulting from successful appealsProvide regular updates to leadership regarding appeal performance and denial trends.ComplianceEnsure compliance with:Ohio Department of Medicaid requirementsOhioMHAS regulationsMedicare regulationsManaged Care Organization (MCO) policiesHIPAA Privacy and Security Rules42 CFR Part 2CARF, Joint Commission, and other accreditation standards, as applicableStay current on payer policy updates, regulatory changes, and industry best practices related to appeals and reimbursement.Secondary FunctionsSecondary Functions are duties, which are not exclusive of the position, can be performed by other positions; however, secondary functions are to be performed for the efficiency of The Counseling Center, Inc.Performs any other duties as assigned by Department Leadership.CompetenciesStrong analytical and critical thinking skills.Excellent attention to detail.Ability to interpret payer manuals, provider bulletins, and medical policies.Strong time management and organizational skills.Excellent written and verbal communication skills.Ability to work independently while managing competing priorities.Commitment to confidentiality and professionalism.Required QualificationsHigh school diploma or GED required; Associate's or Bachelor's degree preferred.Minimum of two years of experience in healthcare appeals, medical billing, denial management, utilization review, or revenue cycle.Experience with behavioral health or substance use disorder services preferred.Knowledge of Medicaid, Medicare, Managed Care Organizations, and commercial insurance appeal processes.Strong understanding of medical necessity criteria, payer policies, and reimbursement guidelines.Excellent written communication skills with the ability to prepare persuasive appeal documentation.Strong organizational skills and the ability to manage multiple deadlines.Proficiency with Microsoft Office and electronic health record systems.Preferred QualificationsExperience with Ohio Medicaid behavioral health services.Knowledge of ASAM Levels of Care and behavioral health documentation standards.Experience working with Ohio Medicaid Managed Care Organizations, including CareSource, Buckeye, Molina, AmeriHealth Caritas, Humana Healthy Horizons, and UnitedHealthcare Community Plan.Experience using payer portals such as Availity and other insurer-specific systems.Experience with NextGen or other behavioral health electronic health record systems.Performance ExpectationsSubmit all appeals within payer-required timeframes.Maintain complete and accurate appeal documentation.Achieve organizational goals for appeal overturn rates and reimbursement recovery.Identify and communicate denial trends to support continuous process improvement.Collaborate effectively with clinical, billing, compliance, and leadership teams to improve reimbursement outcomes.Demonstrate professionalism, accountability, and adherence to regulatory and organizational standards. #J-18808-Ljbffr