Website Cambia Health Solutions
Primary Job Purpose
The Appeals Specialist II is responsible for all activities associated with requests for Provider Billing Disputes and Appeals. Includes analysis, preparation, evaluation of prior determinations, coordination of clinical review if needed, decision making, notification, and completion. Follows guidelines outlined by subscriber or provider contracts, company documents, government mandates, other appeals regulatory requirements and internal policies and procedures. Provides information and assistance to members, providers, other insurance companies, and attorneys or others regarding benefits and claims. Does not make final clinical decisions but has access to licensed health professionals who conduct clinical reviews for appeals.
General Functions and Outcomes
* Responsible for all activities associated with appeal analysis, decision-making and closure as described below:
* Appeal Intake – Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal. Document information in appropriate system.
* Appeal Analysis – Review claim coding and claim processing history, medical policy and reimbursement policies, regulatory and legal requirements, benefit contracts, and/or provider contracts. Collect and catalog supporting documentation and formulate an appeal recommendation. Document information in appropriate system. Apply knowledge and experience to answer a variety of increasingly complex inquiries from members, providers, and provider representatives. Collaborate effectively with coding specialists, appeal nurses, physician reviewers, and others as necessary to reach timely decisions on appeals.
* Decision & Closure – Make non-clinical appeal determinations as permitted by department business processes and guidelines. Follow department’s processes to receive a clinical review and decision from licensed health professionals. Present complex cases to appeal panels, document decisions, communicate determinations to members, providers or their representatives. Document information in appropriate system(s).
* External review process – Oversee set-up of appeals for external review organizations, including document collection and coordination, communication with all parties, and other responsibilities as an intermediary between the provider and the external review organization. Ensure external review information is documented in appropriate system. Prepares letters and cases for external review as needed. Implement external review decisions.
* Interpersonal and Communication – Provide information, education and assistance to members, providers, and their representatives. Facilitate the member’s or provider’s’ understanding of the appeal process and of the information necessary to effectively process an appeal. Be a courteous advocate to the member or provider when requesting supporting information. Work cooperatively and effectively across all business areas to resolve.
* Systems and data – Track appeals in appropriate systems and assist in the maintenance of files. Assist with compilation of reports on appeals, including trends, number of cases, decisions, suggestions for process improvement, types of appeals, and compliance with timelines.
* Support, apply and promote Provider or Member Appeal Policies & Procedures.
* Adhere to dependability, customer focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all work.
* Manage a defined caseload within department productivity and quality expectations and provide back up for other appeals staff.
* May perform as expert witness during any level of appeal, regarding
To view the full job description, click here
To apply for this job please visit www.jobs2careers.com.