Clinical Claims Appeals Specialist

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Summary

The Clinical Claims Appeals Specialist will be responsible for reviewing the clinical components of claims to resolve claims appeals and grievances in accordance with policy and the Centers for Medicare and Medicaid guidelines. A strong knowledge of claims processing, clinical guidelines, and Medicare is required. Reporting to the Manager of Claims, you will be responsible for the claims appeal and grievance work queues which includes, research, resolution, and weekly progress reporting around member and provider appeals and grievances.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current unencumbered licensure with the WV Board of Registered Professional Nurses, or appropriate state board where services will be provided, as a registered professional nurse OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

OR

Current unencumbered licensure with the WV Board of Practical Nursing, or appropriate state board where services will be provided, as a practical nurse AND Three (3) years of clinical experience

EXPERIENCE:

1. Three (3) years' experience with clinical claims processing and review

2. Three (3) years' experience working with appeal and grievances

3. Two (2) years' customer service experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in healthcare, coding, or nursing discipline (/RN/BN) OR Eight (8) years of relevant claims experience in a clinical or insurance setting.

EXPERIENCE:

1. Minimum five (5) years operational managed care experience (call center, appeals, claims environment)

2. Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria with clinical component

3. Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.

4. Three (3) years of direct customer service experience in a healthcare environment

5. Proficient in Medicare/Medicaid guidelines and regulatory requirements

6. Exceptional written and verbal communication skills

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Evaluate and analyze claim appeals to determine their validity and appropriateness.

2. Review medical records, policy terms, and provider agreements to assess claims accurately.

3. Formulates conclusions per protocol assuring timeliness and appropriateness of responses per state, federal and Peak guidelines.

4. Communicate with policyholders to gather additional information, clarify claim details, and explain the appeal process.

5. Ensure a high level of customer service and empathy when addressing member concerns.

6. Collaborate with healthcare providers, billing offices, and internal teams to collect supporting documentation and clarify claim details.

7. Work closely with the Claims Department to ensure timely resolution and processing of appeals.

8. Maintain accurate and detailed records of all appeal cases, including correspondence and relevant documents.

9. Prepare comprehensive appeal reports for management and regulatory compliance.

10. Stay up-to-date with relevant healthcare laws, regulations, and policies to ensure that the appeal process remains compliant.

11. Identify opportunities to enhance the appeal process and recommend improvements to streamline procedures and enhance efficiency.

12. Provide guidance and training to other team members and employees on claims appeal processes and best practices.

13. Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors.

14. Resolves and prepares written responses to incoming provider reconsideration requests relating to claims payments, requests for claim adjustments or for requests from outside agencies

15. Any other duties needed as requested by Claims leadership

PHYSICAL REQUIREMENTS: 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.

• Ability to sit and work at a computer for the majority of a normal workday.

WORKING 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.

1. Standard office environment

2. Some travel may be required to offsite meetings

SKILLS AND ABILITIES:

• Strategic thinking
• Demonstrated knowledge of federal and state laws, such as CMS, BMS, etc.
• Excellent written and oral communication
• Demonstrated ability to build and retain relationships
• Attention to detail
• Proficiency with Microsoft Office

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance
• Work from home

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• Hybrid work
• Office

Application Question(s):

• Do you have at least three (3) years' experience with clinical claims processing and review?
• Do you have at least three (3) years' experience working with appeal and grievances?

Experience:

• Customer service: 2 years (Required)

License/Certification:

• RN License (Preferred)
• LPN (Preferred)

Work Location: Hybrid remote in Morgantown, WV 26505