Compensation Overview

POSITION SUMMARY:

The Appeal Analyst is responsible for researching 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 appeal process and submission.

PRIMARY RESPONSBILITIES:

● Develop, train, and deploy a process to submit and monitor 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 (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 appeal resolution.
● Works closely with the vendor operations teams to oversee operations activity that directly impact
assigned product 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.
● Performs other duties as assigned

QUALIFICATIONS:

● Bachelors Degree in a healthcare related field of study, or equivalent experience.
● Minimum of 5 years of experience in medical billing and Insurance collections, dispute resolution.
● Minimum of 3 years appeals experience preferred.
● Minimum of 3 years of experience in revenue cycle or claim analysis
● Project management experience preferred.
● Knowledge of CPT/HCPCS. ICD-10, modifier selection, and UB revenue codes.

REQUIRED 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.