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Appeals Analyst II - Health

196063 Requisition #

The Healthcare Appeals Analyst is responsible for monitoring contractual allowances, analyzing and pursuing appeal opportunities with payers and networks, and reporting appeals performance. 
Essential Functions:
• Implements process for identifying under-allowed claims using software and other available tools.
• Reviews and analyzes EOBs for identified under-allowed claims.
• Verifies applicable contract by, as dictated by operational procedures: reviewing EOB messages, reviewing patient ID card, verifying member information for managed care plans.
• Uses feedback and experience to refine communication skills and tools for use in preparing written and telephone appeals.
• Batches appeals by payer or network, by CPT/HCPCS code combination, by error type, or by provider.
• Compiles and submits appeals, and monitors for proper reimbursement.
• Uses software to track appeals and recoveries.
• Establishes and cultivates helpful and effective contacts in payer or network offices.
• Establishes follow-up protocol with payers and networks.
• Prepares monthly performance statistics regarding appeals and recoveries.
• Monitors and tracks contractual, billing, registration, and posting errors, and provides continuous feedback to Appeals Manager.
• Participates in meetings to discuss ongoing trends and issues regarding the administration of managed care contracts.
• Maintains the strict confidentiality required for medical records and other data.
• Participates in professional development efforts to ensure currency in managed care reimbursement trends. 

Education and Experience: 
• Associates degree preferred
• Minimum of two years’ experience working with managed care claims and appeals for health care professional services (physicians and other health care professionals).
• Experience in a production environment desirable but comfort in such an environment is essential.
Equivalent combination of education and experience may be considered

• Advanced knowledge and PC skills, with proficiency in utilizing Microsoft office products (Word, Excel, Outlook, PowerPoint, etc.)
• Knowledge of the health care professional services billing (physicians and related health care professionals) and reimbursement environment.
• Knowledge of major types of practice management system (PMS) and EOB imaging systems, with experience working with at least one industry leading PMS highly desirable.
• Knowledge of medical terminology.
• Knowledge of networks, IPAs, MSOs, HMOs, PCP and contract affiliations.
• Knowledge of managed care contracts and compliance.
• Demonstrated skill in gathering and reporting claims information.
• Demonstrated skill in written and oral communication with colleagues, supervisors, and payer/network personnel.
• Demonstrated skill working in a team-oriented structure to achieve goals.
• Demonstrated skill in problem solving and research. 
• Ability to work effectively with other departments and management.
• Ability to identify, analyze and solve problems and to recognize patterns in data.
• Ability to learn, understand and use the software application.

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