AR Appeals Specialist

Position Summary:  The AR Appeals Specialist will submit appeals to payers and follow up as needed. These will be high level appeals requiring in depth understanding of Oncology Accounts Receivable. Knowledge of constantly changing insurance carrier rules/requirements is needed as well as flexibility and persistence.  Skills are analytical and accounting type in nature, with the ability to communicate well with the patients and the insurance carriers.   Work is performed under the general direction of the Revenue Cycle Supervisor.

Essential Duties and Responsibilities:

• Works closely with FlatIron Accounts Receivable partner to assist and answer escalated issues via onsite queries.
• Reviews daily requests for appeals, including high level appeals, from FlatIron. Research, compose, and upload necessary documentation for appeals submissions
• Assesses proper payments and adjustments on individual bills or an entire patient account for accuracy of processing and take the appropriate action if done incorrectly-overpayments, underpayments, and no payments.
• Resolves billing issues/questions from both insurance carriers and patients by phone, fax, or mail.
• Interfaces with Coding, Medical Records, and Patient Representatives verifying accuracy of information submitted on denied claims, using charts for audit and/or verification purposes and resolving insurance issues and referral pre-certs. Also interfaces with Insurance companies and patients regarding billing and reimbursement issues and answering questions/explanation of bills.
• Respects the dignity and confidentiality of patients.
• Possesses good communication skills that lend to a team oriented work environment.
• Performs other duties as assigned.

Qualifications/Experience:

Associate’s degree or equivalent from two-year college or technical school; or 5 years’ related experience and/or training; or equivalent combination of education and experience

A proven track record with appeals composition and successful resolution of escalated appeals with payers.  Second level or high level appeals desired. 

Experience with appeals or claims escalation with assigned Provider Representative from various insurance companies a plus.

In depth clinical knowledge including reviewing coding edits and practices (CCI edits, NCCN guidelines) are highly desired.  An excellent working knowledge of insurance carriers’ payment regulations including reimbursement schedules, denials reasons, precertification requirements, and network participation.

Must have excellent organization and follow-up skills; excellent verbal and written communication skills; excellent problem-solving skills; ability to organize and prioritize work assignments; ability to handle multiple priorities in a fast-paced environment; ability to analyze situations and respond in a timely manner; ability to participate in multi-functional teams; ability to establish and maintain effective working relationships within The West Clinic. Must be proficient in computer applications including word processing and e-mail with the ability to perform 10 key by touch.  Additional hours may be required.

Work Environment/Physical Demands/Travel:

• Typical clinical environment with moderate noise level.
• Ability to stand, walk, sit and use hand/wrist, talk, hear, see, and stoop or crouch for extended periods of time.
• Ability to read and understand documents such as safety rules, operating and maintenance instructions, procedure manuals, correspondence. Ability to write routine reports and correspondence.  Ability to speak and present information in small groups of customers, suppliers, or employees of the company.
• Ability to calculate figures and amounts such as discounts, interest, commissions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
• Ability to apply common sense understanding to carry out instructions given in written, oral, or diagram form. Ability to deal with problems involving a few concrete variables in routine situations.
• Ability to lift up to 25 lbs.
• Some travel may be required.