Clinical Appeals Specialist - Clinical Appeals

Summary:

This position requires the ability to work independently researching and reviewing inquiries from members and providers. Also requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding. Responsible for analyzing, researching, and managing appeal/grievance inventories from members and providers. Respond to inquiries using verbal and written forms of communication.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests.
• Review and respond to complaints, grievances and appeals within the stated time frame for each request.
• Ensure 95% compliance with the Center for Medicare and Medicaid Services (CMS) guidelines is met by adhering to all state and federal regulations.
• Analyze and resolve customer inquiries by adhering to CMS guidelines and CHRISTUS Health internal policies and procedures.
• Actively communicate with other associates to guarantee accurate and timely responses to inquiries involving internal/external customer needs.
• Be proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summary.
• Certify that providers and members are reimbursed accordingly using Medicare reimbursement policies and procedures.
• Has the ability to communicate with multiple levels in the organization (e.g. managers, clinical, and support staff).
• Has excellent organizational skills including effective time management, priority setting and process improvement.
• Understands the difference in billing, collections, payments, and refunds for governmental, managed care, and commercial payers.
• Possess an understanding of accounts receivables and claim denials.
• Knowledgeable and/or previous experience in Medicare Recovery Audits and managed care audit processes.
• Has clear concise verbal and written communication skills.
• Has time management/Decision making/Problem Solving.
• Has phone etiquette.
• Has multi-tasking ability.
• Able to work independently and within team environment.
• Knowledge of general medical terminology, CPT, ICD-9 and ICD-10 coding.

Job Requirements:

Education/Skills

• Bachelor's Degree or equivalent years of relevant work experience required.

Experience

• A minimum of (5) years of healthcare customer service, claims, denials, appeals, compliance, or related experience is required.

• Strong background in the healthcare field is required.

• Computer experience in Microsoft Office (Word and Excel) required.

Licenses, Registrations, or Certifications

• None required.

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time