Appeals/Denials Specialist

Description

This person will be on the bill review team specifically working in the backlog of appeals. The Bill Review Analyst position holds accountability for accurate and timely review, processing and payment of bills to include pre-coding accuracy and adjudication of appeals/provider reconsideration requests.

• Examines and adjudicates requests for appeals, reconsiderations, re-evaluations, and corrected bills.

• Maintains knowledge of industry standard medical coding initiatives and state specific fee schedules and coding guidelines

• Meets or exceeds department contractual and/or industry standards for accuracy and turnaround time

• Maintains an understanding of all variations of Workers’ Compensation state rules and regulations

• Maintains comprehensive knowledge of all available re-pricing opportunities (e.g. PPOs, direct contracts, etc.), ensures application as part of the adjudication process

• Monitors itemized billings for excessive charges, duplications, and appropriate medical bills coding

• Reviews/processes appeals and initiates refund requests, assists in the recoupment process.

• Assists in the preparation of bills research reports

Skills

workers' compensation, appeals, bill review software, data entry