Appeals Specialist

Appeal Specialist I Work from home Within Oregon, Washington, Idaho or Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Every day, Cambia's dedicated Appeal Specialist, are living our mission to make healthcare easier and lives better. As a member of the Appeals team, our Appeal Specialist Responsible for all activities associated with requests for Provider Billing Disputes and Appeals. Includes analysis, preparation, evaluation of prior determinations, coordination of clinical review if needed, decision making, notification, and completion. Follows guidelines outlined by subscriber or provider contracts, company documents, government mandates, other appeals regulatory requirements and internal policies and procedures.

Provides information and assistance to members, providers, other insurance companies, and attorneys or others regarding benefits and claims. Does not make final clinical decisions but has access to licensed health professionals who conduct clinical reviews for appeals, all in service of creating a person-focused health care experience.

Do you have a passion for serving others and learning new things? Do you thrive as part of a collaborative, caring team? Then this role may be the perfect fit.

Every day, Cambia's dedicated Appeal Specialist, are living our mission to make healthcare easier and lives better. As a member of the Appeals team, our Appeal Specialist Responsible for all activities associated with requests for Provider Billing Disputes and Appeals. Includes analysis, preparation, evaluation of prior determinations, coordination of clinical review if needed, decision making, notification, and completion. Follows guidelines outlined by subscriber or provider contracts, company documents, government mandates, other appeals regulatory requirements and internal policies and procedures.

Provides information and assistance to members, providers, other insurance companies, and attorneys or others regarding benefits and claims. Does not make final clinical decisions but has access to licensed health professionals who conduct clinical reviews for appeals, all in service of creating a person-focused health care experience.

• High school diploma or GED required
• Minimum 4 years' experience in Customer Service, Claims, or Clinical Services, or equivalent combination of education and work experience
• Coding Certification (CPC, CCS, or similar) preferred

• Excellent verbal and written communication skills with ability to present complex medical and reimbursement information diplomatically and persuasively regarding health plan benefits, claims, and eligibility
• Intermediate computer skills including Microsoft Word, Excel, and Outlook, with experience using Regence systems
• Knowledge of medical terminology, anatomy, and coding systems (CPT, DX, HCPCs) along with understanding of claims processing and clinical services operations
• Demonstrated initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing effective courses of action
• Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all internal and external contacts
• Ability to switch from one task or type of work to another as business needs require while effectively prioritizing work to meet strict timelines and maintaining quality and consumer-centric focus
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

• Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal and document information in appropriate system
• Review claim coding, claim processing history, medical policy, reimbursement policies, regulatory and legal requirements, benefit contracts, and provider contracts; collect and catalogue supporting documentation; formulate appeal recommendations; answer increasingly complex inquiries from members, providers, and representatives; collaborate with coding specialists, appeal nurses, physician reviewers, and others to reach timely decisions
• Make non-clinical appeal determinations as permitted by department business processes and guidelines; follow processes to receive clinical review and decisions from licensed health professionals; present complex cases to appeal panels; document decisions and communicate determinations to members, providers, or their representatives in appropriate system(s)
• Oversee set-up of appeals for external review organizations including document collection and coordination, communication with all parties, and serve as intermediary between provider and external review organization; prepare letters and cases for external review; implement external…