APPEALS SPECIALIST

APPEALS SPECIALIST

Job Summary

Responsible for denial management on all governmental and commercial payers, including inpatient and outpatient claims.

Job Responsibilities

• Conducts chart audits to determine most appropriate course of action when payer denial received.
• Composes credible appeal letters, utilizing : Federal and State regulations; Center for Medicare and Medicaid (CMS) Guidelines and policies; Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS) payment; ICD-10M Official Guidelines for Coding and Reporting; AHA Coding Clinics; InterQual Medical Necessity criteria; Current Procedural Terminology (CPT) Guidelines; Medical Standards of practice; and published articles, journals and clinical studies.
• Collaborates extensively with Business Office / HIM / Auditing / Finance / Medical Director of Case Management / and others as appropriate in order to obtain resolution of denial.
• Effectively researches each case in search of data necessary to decide if case warrants appeal.
• Identifies and reports trends and issues to stakeholders.
• Examines the reason for denial and looks for inconsistencies inside of the option.
• Maintains up-to-date knowledge of CMS regulations and appeal rights.
• Enters accurate data related to the appeal process into system databases.

Qualifications

Skills and Attributes

Physical Demands

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.

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