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Appeals Specialist

Company: Creative Financial Staffing
Location: Fort Wayne
Posted on: January 12, 2021

Job Description:

Position SummaryThe Appeals Specialists main function is to timely analyze, process and respond to Provider appeals related to payment denials of provider claim within the regulatory timelines set forth by the governing bodies and pursuant to contractual obligations. The Appeals Specialist will also, conduct and record daily functions to ensure proper communication and documentation is made internally and externally. Duties and Responsibilities * Research and review appeal submissions to determine if eligible for appeal based on defined criteria. * Research and prepare all qualifying appeals as assigned for Medicare, Medicaid, MMA, Commercial and Exchange lines of business. Classification for appeals may include the following: Payment disputes, filing limit disputes, denials for no authorization, benefit disputes, claim billing disputes, etc. * Review cases thoroughly to convey concise and accurate information for resolution based on, but not limited to, the following critical knowledge bases: general coding and billing policy, member eligibility, government and company compliance, provider contracts and terms, Network policies, correct coding including modifiers, CPT codes, place of service, authorizations, and referral requirements. * Consult with secondary reviewers such as Utilization Management and Claims Manager when needed. * Forward qualifying appeals for final review to Claims Manager and/or Medical Directors based on defined criteria. * Respond to any requests for additional information or consultation on appeals submitted to other departments and/or the Medical Directors. * Prepare notification and return documentation for incomplete or improperly submitted requests to the provider. Process non-appeals (i.e., refunds, adjustments, corrected claims, etc.) if necessary as defined by the submission type (i.e. First-time filing, submission of medical records, etc.) * Document, correspond and communicate with providers as needed and when required during appeal processing. * Properly document, track and process all appeals through the internal system. * Responsible for documenting and processing all Refund Requests made for over-payments made by the Network. * Ability to perform all other duties as assigned or reques Click here to apply online

Keywords: Creative Financial Staffing, Fort Wayne , Appeals Specialist, Other , Fort Wayne, Indiana

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