Provider Appeals Coordinator - Contract (6 months)
Company: Abacus Service Corporation
Posted on: November 24, 2022
Job Type: Contract
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
" 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
" 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
" 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
**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.
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 Start Date:
Number of Positions:
Number of Weeks:
Maximum Submissions Per Job:
State License Details:
Holiday Coverage Required:
Minimum Years of Experience:
Specialty and Certification Information
Will facility accept 1099?:
Incidentals provided by facility:
Keywords: Abacus Service Corporation, Reno , Provider Appeals Coordinator - Contract (6 months), Other , Reno, Nevada
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