Clinical Appeals Specialist - TLRA Revenue Cycle

DescriptionSummary: 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: Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requestsReview and respond to complaints, grievances and appeals within the stated time frame for each requestEnsure 95% compliance with the Center for Medicare and Medicaid Services (CMS) guidelines is met by adhering to all state and federal regulationsAnalyze and resolve customer inquiries by adhering to CMS guidelines and CHRISTUS Health internal policies and proceduresActively communicate with other associates to guarantee accurate and timely responses to inquiries involving internal/external customer needsBe proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summaryCertify that providers and members are reimbursed accordingly using Medicare reimbursement policies and procedures Requirements: Bachelor's Degree or equivalent years of relevant work experience preferred.Ability to communicate with multiple levels in the organization (e.g. managers, clinical, and support staff).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.Clear concise verbal and written communication skills.Time management/Decision making/Problem Solving.Phone etiquette.Multi-tasking ability.Able to work independently and within team environment.Computer experience in Microsoft Office (Word and Excel).Knowledge of general medical terminology, CPT, ICD-9 and ICD-10 codingA 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. Work Type: Full Time EEO is the law - click below for more information:  https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at (844) 257-6925. Additional Information: - Specialty: Billing and Insurance Specialist - Location: 2900 North Loop WestHouston, Texas 77092 - Contact: About the Company: CHRISTUS Health is an international Catholic, faith-based, not-for-profit health system comprised of more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. Sponsored by the Sisters of Charity of the Incarnate Word in Houston and San Antonio and the Sisters of the Holy Family of Nazareth, the mission of CHRISTUS Health is to extend the healing ministry of Jesus Christ. To support our healthcare ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on staff who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States. EXTENDING THE HEALING MINISTRY OF JESUS CHRIST We are inspired by our mission, vision and core values to deliver compassionate, high quality health care, improving the health of the communities we serve. Above all, we are committed to providing our customers and their family members with a truly unique healing experience, one that embodies our values and respects the dignity and worth of each person. Creating a health care system that is truly excellent in all areas is an ongoing effort.