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Provider Appeals Coordinator - Contract (6 months)

Company: Abacus Service Corporation
Location: Reno
Posted on: November 24, 2022

Job Description:

Job Type: Contract

Job Description:
This position is accountable for the comprehensive review, research and resolution of appeals submitted by providers. This position is required to apply analytical and critical thinking when reviewing contract language, benefits, and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of Insurance.

This position will be responsible to keep overall service issues in mind while resolving individual cases.

" Must have a thorough understanding of Health Plan operations and business unit processes, workflows, and system requirements, including but not limited to, authorizations, billing, claims, regulatory compliance, and plan benefits. " Review and evaluate Medicare, Commercial and Self-Funded appeal requests in order to identify and triage provider appeals.

" Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Hometown Health guidelines.

" Prepares case files (original denial, all information received on appeal, medical records, and case summary for external reviewers, DOI, 2nd level review committee, OCHA, and/or arbitrators.

" Maintains accurate, timely, and complete record of appeals in the appeals system and documents all correspondence with a provider.

" Ensure accuracy and compliance to scheduled regulatory deadlines. Monitors caseload daily to ensure all cases are kept in compliance, follows up and escalates when compliance standards are at risk.

" Initiate and follow up on the effectuations (UM authorization/claim adjustment) for overturned appeals.

" Collaborate with clinical staff for clinical related questions or issues. Licensed health professionals are on site as well as available virtually. KNOWLEDGE, SKILLS & ABILITIES " Working knowledge of medical billing practices to include, but not limited to medical terminology, CPT ICD9/10, and HCPCS coding.

" The ability to communicate professionally and diplomatically, clearly, and concisely, both verbally and in writing.

" The ability to maintain confidentiality of medical and personal information of all customers.

" The ability to ensure all goals and deadlines are met.

" Demonstrated skills in problem identification, problem solving and process improvement.

" Masters' CMS regulations for handling Medicare appeal cases.

" Ability to Interpret and explain the benefits, policies and procedures to providers as they relate to appeals. Communicate with providers as necessary to provide updates or obtain additional information needed for decision making.

" Ability to track and monitor movement of assigned cases through functional units and systems while ensuring that resolution meets established timelines.

" Follow-up with responsible departments and delegated entities to ensure compliance. " Document final resolutions along with all required data to facilitate accurate reporting.

" Ensures final resolution letters are generated within the required timelines.

**Experience: Three years' experience processing health insurance appeals or equivalent experience in health insurance claims. Strong knowledge of claims operations and health plan customer service policies, procedures, and systems. Knowledge of state and federal insurance regulations with emphases on the Centers for Medicare and Medicaid Services (CMS). Must have excellent verbal and written communication and organizational skills.

Sub Specialty(s):
Clerical Generalist

Additional Information And Terms
UPDATE: As of 6/12/20, Renown Reserves the right to call off, without penalty, FOUR (4) shifts, or 48 hours, for low census per 13 week contract. This may be full or partial shifts. **Renown does NOT hire travelers/contractors that have a permanent address within sixty (60) miles of the facility.

Job Details

Job Start Date:
Number of Positions:
Number of Weeks:
Maximum Submissions Per Job:
Shift Information:
State License Details:
Not Needed
Holiday Coverage Required:
EMR Used:
No Listing
Minimum Years of Experience:

Specialty and Certification Information

Specialty Information
Specialty Type:
Sub Specialties:
Clerical Generalist

Will facility accept 1099?:
Incidentals provided by facility:
Mileage Reimbursement:
Mileage Details:

Keywords: Abacus Service Corporation, Reno , Provider Appeals Coordinator - Contract (6 months), Other , Reno, Nevada

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