The Appeal Analyst is responsible for researching non-clinical claims that are eligible for an appeal for their assigned product.  This position develops the appeal letter, package, and process for the billing vendor to execute while overseeing the non-clinical appeal process and submission. 

PRIMARY RESPONSIBILITIES: 

• 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.

QUALIFICATIONS:

• 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.

KNOWLEDGE, SKILLS, AND ABILITIES:

• 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.

The pay range for this role is $80,000 - $90,000. Actual compensation packages are based on a wide array of factors unique to each candidate, including but not limited to skill set, years & depth of experience, certifications and specific office location. This may differ in other locations due to cost of labor considerations.  

#LI-NM1

#LI-Remote