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Appeal Analyst
Posted on 3/31/2023
Experience Level
  • Bachelor's Degree healthcare related field of study or equivalent experience
  • Minimum of 5 years appeals experience
  • Minimum of 5 years of Utilization Management experience
  • Minimum of 5 years of experience utilizing medical decision support tools or medical policies
  • Minimum of 5 years of experience in medical billing and Insurance collections, dispute resolution
  • Minimum of 3 years of experience in revenue cycle or claim analysis
  • Active, unrestricted state Registered Nurse (RN) license preferred
  • Minimum of 3 years of experience with Quality Accreditation Standards (JCAHO/ NCQA/ URAC) preferred
  • Project management experience preferred
  • Proficiency with medical or claim billing systems, Microsoft Excel, reporting software and basic procedure coding knowledge
  • Knowledge of medical terminology and abbreviations, and health care nomenclature and systems
  • Strong communication (verbal and written), organizational, problem solving and team player skills
  • Knowledge of appeal process and procedures
  • Ability to navigate across multiple customer demands and balance competing priorities successfully
  • Ability to analyze, identify and articulate identified trends and report trends succinctly in a clear and concise manner
  • Ability to independently solve complex problems using critical thinking skills
  • Maintains confidentiality of sensitive information
  • Analytical skills required
  • Ability to develop, implement and produce complex analysis and reports
  • Develop, train, and deploy a process to submit and monitor non-clinical appeals for assigned product. This includes the required appeal letter and package
  • Establishes the patient authorized appeal process for medical necessity and experimental denials
  • Project manages patient authorized appeals to see cases are sent to external review
  • Expand and exhaust provider level appeals for non-clinical denials (including but not limited to underpaid, out of network, Prior auth, bundling, coding appeals)
  • Monitors claims, identifies trends, presents opportunity areas, and prioritizes initiatives for performance improvement for assigned product
  • Conducts monthly audits on third-party vendor to ensure process and workflows are being adhered and payment accuracy against contracted reimbursement rate
  • Establishes an ongoing working relationship with other departments impacting non-clinical appeal resolution
  • Works closely with the vendor operations teams to oversee operations activity that directly impact assigned product non-clinical appeal process
  • Tracks appeal outcomes for assigned product to ensure KPIs and goals are met
  • Participates in weekly meetings to review key metrics, workflows, trends, and performance improvement opportunities
  • Continually reviews and monitors payor appeal changes to determine process update and actions
  • Coordinates with Management to ensure thorough understanding of trends/issues affecting assigned appeal performance

1,001-5,000 employees

Clinical genetic testing
Company Overview
Natera's mission is to change the management of disease worldwide with a focus on reproductive health, oncology, and organ transplantation.
  • Flexible medical plans
  • Investment options
  • Time off
  • Workplace perks
Company Core Values
  • A person behind every sample
  • Embrace diversity
  • Be accountable
  • Think team
  • Learn and nimble
  • Show me the data
  • Be ready to change the world
  • Integrity is in our DNA