Appeals Specialist

Under the general guidance of the Patient Access Services Denial Manager, the Admitting Department Appeals Specialist is responsible for assisting with insurance denials and is expected to adhere to programs, policies, and procedures to maximize reimbursement by minimizing denials. Under the supervision of the Patient Access Manager, the Appeals Specialist also monitors Huron and EPIC reports and work queues to ensure timely response to denied cases, prepares and submits appeals, and provides follow-up on cases until resolution has been achieved.

Reviews appealed cases to assist in the determination of departmental write-offs, as appropriate. Cultivates, maintains, and enhances relationships with third-party payors. The analyst performs all these functions in a manner that complies with standards established by the Hospital Administration, Medical Staff, and outside regulatory and accreditation agencies. Works toward goals and objectives for departmental denial management.

• Has a sound understanding of the payer rules related to the denials and appeals.
• Communicates directly with payers, Payor Operations, BWF and BWH Case Management, Admitting, Revenue Operations, Central Billing Office, and other appropriate hospital and physician staff to coordinate appeal activity if deemed necessary.
• Cultivates, maintains, and enhances relationships with third-party payors.
• Provides case follow-up on denials until resolution has been achieved.
• Formulates and submits timely, well-prepared appeals with supporting clinical information and required data and provides this information to third-party administrators (payers).
• Assists in the determination of write-offs and analysis provided to the Executive Director for review and approval.
• Reviews Huron and EPIC reporting and documentation to determine the root causes for denials and works to implement action plans to prevent future denials.
• Maintains clear channels of communication for effective problem-solving, as related to denials, and troubleshoots routine and non-routine problems and takes appropriate actions to address issues.
• Contributes to teamwork within and between departments. Attends and participates in related meetings as needed.
• Positively provides constructive ideas and suggestions.
• Works collaboratively with co-workers and management to effectively resolve issues that impact departmental or hospital operations in order to increase reimbursement and minimize denials.
• Performs various administrative functions, including, but not limited to, supporting management of payer contractions and contract operations around denials including compiling and summarizing denial data and trends in Excel and Word to support meetings and events.
• Assists in the design and implementation of programs to monitor denial and reduce denials.
• Works efficiently to meet appeal response deadlines (i.e. fax, telephone, online, etc.) - Assists in the implementation of Quality Assurance programs targeting as goals not only accuracy and efficiency but also high levels of patient and physician satisfaction.
• Assists in the development of functional specifications/requirements for computer systems, new computer programs, and enhancements to existing systems.
• In conjunction with Information Systems, Care Coordination, and the Finance Department, assists in the design, creation, and verification of EPIC and Huron Reporting and dashboards.
• Assures accuracy and completeness of data collected by Patient Access Services and submitted to third-party payors.
• Works with Information Systems regarding system maintenance, enhancements, and/or upgrades.
• Develops manual procedures to handle computer downtime and crash recovery.
• Creates an environment that encourages productivity, loyalty, job satisfaction, and a positive attitude.
• Adheres to the hospital's personnel policies and procedures.
• Assists management with analysis related to operating and capital budgets.
• Generates and implements new ideas for reducing costs.
• Actively participates in designated special projects as needed.
• Maintains ongoing knowledge of legislative and regulatory changes that impact hospital access to care and quality of care.

• High School diploma/GED required.
• Bachelor's degree in business, accounting, or healthcare-related field preferred.
• Minimum of 2-4 years in a health care setting with administrative and financial work experience
• Denials or appeals experience required.
• Requires effective, results-oriented skills.
• Requires interpersonal skills to interact effectively with all levels of staff, management, and leadership.
• Must be able to collaborate in an effective interdisciplinary team approach.
• Requires superior problem-solving skills and the ability to work with multiple demands and priorities.
• Requires independent judgment to deviate from standard policies, procedures, and schedules when necessary.
• Requires excellent communication skills both oral and written.
  
  - Requires sound analytical skills.
• Requires knowledge of computers and…