上诉专员 II - 远程
Appeals Specialist II - REMOTE
福利
- 全面的健康保障 – 包括医疗、牙科和视力保险，保障您和家人的健康
- 未来保障：401(k) 退休计划并提供匹配
- 学生贷款支持 – 最高可达 10,000 美元的还款援助，因为我们投资于您的未来
- 教育学费补助
- 竞争性薪资与全面福利 – 薪资和福利组合旨在奖励您的专业技能和奉献精神
职位概述
理赔专员 II 负责审查、分析和解决保险拒付情况，以确保准确的报销和合规性。该职位记录并审查拒付情况用于趋势报告，向相关部门提供反馈，并向相关利益方传达付款方的更新信息。理赔专员 II 与内部团队协作，确保及时且彻底地解决上诉，并支持改进拒付预防和追回流程的项目。
主要职责
- 使用 MCG、InterQual、CMS 和其他指南提交医疗必要性和护理等级上诉。根据需要提交其他临床上诉，包括但不限于与再入院、实验性和研究性判定以及基于覆盖范围的判定相关的拒付类型。
- 监控临床上诉流程中的问题和趋势，并在需要时向相关部门提供指导和反馈。
- 使用现有工具（手册、培训项目）跟踪和管理临床拒付。
- 识别拒付中的模式和趋势，并向相关人员沟通。
- 保留所有付款方资源关于拒付和上诉流程的文档。
- 理解并应用 CHS 上诉流程处理被拒的索赔。
- 遵守患者和医院的安全实践，报告安全隐患并采取适当行动。参与安全培训项目。
- 通过专业沟通、及时回应查询和建立积极的工作关系，为患者、家属、重要他人、医生、同事和外部供应商提供优质的客户服务。
- 按照 Artiva、HMS 和其他办公系统中的文档标准记录所有操作。
- 理解并应用保险公司、监管机构和其他适用实体的政策和程序手册及其他参考资料。
- 通过遵循 HIPAA 指南，确保所有患者账户的机密性。
- 执行
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Benefits
- Comprehensive Health Coverage – Medical, dental, and vision plans to keep you and your family healthy.
- Future Security: 401(k) with matching
- Student Loan Support – Up to $10,000 repayment assistance, because we invest in your future.
- Educational Tuition Assistance
- Competitive Pay & Full Benefits – A salary and package designed to reward your expertise and dedication.
Job Summary
The Appeal Specialist II reviews, analyzes, and resolves insurance denials to ensure accurate reimbursement and regulatory compliance. This role logs and reviews denials for trend reporting, provides feedback to facilities, and communicates payer updates to relevant stakeholders. The Appeal Specialist II collaborates with internal teams to ensure timely and thorough appeal resolution and supports initiatives that improve denial prevention and recovery processes.
Essential Functions
- Files medical necessity and level of care appeals using MCG, InterQual, CMS, and other guidelines as needed. Files other clinical appeals on in scope denial types including, but not limited to denials surrounding readmissions, experimental and investigational determinations, and coverage based determinations.
- Monitors clinical appeal processes for issues and trends and provides guidance and feedback to related departments as needed.
- Tracks and manages clinical denials using current tools (manuals, training programs).
- Identifies patterns and trends in denials; communicates to appropriate persons.
- Maintains documentation regarding all payer resources regarding denials and appeals processes.
- Understands and applies CHS Appeal Process for denied claims.
- Follows and enforces accepted safety practices for patients and the hospital. Reports safety hazards and initiates appropriate action. Participates in safety instructional programs.
- Provides excellent customer service to patients, families, significant others, physicians, coworkers, and external vendors by communicating professionally, responding promptly to inquiries, and fostering positive working relationships.
- Documents all actions accordingly by documentation standards within Artiva, HMS and other business office systems as required.
- Understands and applies policy and procedure manuals and other reference materials from insurance companies, regulatory organizations, and other in scope applicable entities.
- Ensures confidentiality of all patient accounts by following HIPAA guidelines.
- Performs other duties as assigned.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
Qualifications
- Associate Degree in Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy required
- Bachelor's Degree in Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy preferred
- 3-5 years of experience in clinical operations in Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy required
- 1-3 years of experience in claims processing, healthcare billing, or revenue cycle management preferred
- 1-3 years of experience in utilization review and/or case management experience leveraging MCG or InterQual preferred
Knowledge, Skills and Abilities
- Basic knowledge of medical billing, coding systems, and insurance claim processes.
- Strong communication skills for interacting with insurance carriers, patient financial service units, and other departments.
- Detail-oriented, with strong organizational and time management skills to manage a high volume of appeals.
- Proficiency in using healthcare billing software and Google Suite.
Licenses and Certifications
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
- PT - Physical Therapist required or
- OT - Occupational Therapist – Registered required or
- SLP - Speech Language Pathologist required
The Payment Compliance and Contract Management (PCCM) team plays a critical role in ensuring that payments are made according to contractual agreements and regulatory requirements. The team oversees the full contract lifecycle, focusing on analyzing reimbursement discrepancies, improving revenue cycle processes, and ensuring compliance with contract terms to support financial accuracy and operational efficiency.
Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 71 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.
Originally posted on Himalayas