Claims & Appeals Specialist Job at Baxter (Saint Paul)

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

Medical Billing Specialist

We are looking for a detail-oriented Medical Billing Specialist to join a team i...

Location

United States , King of Prussia

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

At least 1 year of experience in medical billing, claims, or collections
Proficiency in accounting software systems and electronic health record (EHR) systems
Familiarity with Medicaid processes and commercial insurance claims
Strong understanding of accounts receivable, denial management, and appeals
Experience working with billing and authorization functions
Ability to accurately input and manage billing data
Excellent communication skills to collaborate with team members and external payors
Knowledge of compliance policies related to medical billing and collections

Job Responsibility

Process and submit primary and secondary claims for both commercial insurance and Medicaid
Investigate and resolve claim denials, performing appeals as necessary to ensure proper reimbursement
Manage accounts receivable by following up on claims through resolution, including correcting billing errors and addressing rejections
Input and review billing data for accuracy, ensuring compliance with company policies and procedures
Collaborate with the Billing Manager and clinic teams to ensure accurate and timely billing
Track and verify Medicaid status for clients while maintaining relationships with payors to facilitate successful claims processing
Assist intake teams with Medicaid documentation for new clients and those requiring reassessment
Utilize various insurance portals and systems, including Waystar, to handle denial responses and claims follow-ups
Ensure adherence to compliance standards in all billing and collections activities
Perform other tasks as assigned by the Billing Manager or Director

What we offer

Medical insurance
Vision insurance
Dental insurance
Life insurance
Disability insurance
401(k) plan

Fulltime

Medical Reimbursement Specialist

We are in search of a Medical Reimbursement Specialist to join our team. Station...

Location

United States , Princeton

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Minimum of 3 years of experience in a similar role
Proficient in benefit functions
Demonstrated expertise in billing functions
Experience in claim administration
Familiarity with collection processes
Ability to handle and resolve medical denials
Comprehensive knowledge of Medicare

Job Responsibility

Analyze and categorize outstanding claims based on payer, denial reason, and claim value
Investigate and take corrective action on unpaid, denied, or underpaid claims
Collaborate with internal teams to obtain missing documentation and expedite claim resubmission
Evaluate common denial reasons and address them accordingly, such as coding errors, medical necessity, and prior authorization
Submit corrected claims and formal appeals as required
Communicate with insurance payers to resolve aged claims and escalate unresolved claims as necessary
Maintain comprehensive records of all payer interactions
Identify the root causes of denials and implement best practices to prevent future issues
Suggest changes to workflow to enhance claim submission accuracy and speed
Conduct training for in-house billing teams on claim recovery strategies

What we offer

medical, vision, dental, and life and disability insurance
eligibility to enroll in company 401(k) plan

Fulltime

Appeals Specialist I

Responsible for all activities associated with requests for Provider Billing Dis...

Location

United States , Portland

Salary:

25.00 - 30.00 USD / Hour

Apex Systems

Expiration Date

Until further notice

Requirements

Excellent verbal and written communication skills
Intermediate computer skills (e.g. Microsoft Word, Excel, Outlook)
Knowledge of medical terminology, anatomy and coding (CPT, DX, HCPCs)
Knowledge of claims processing and clinical services operations
Demonstrated initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing a course of action
Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all aspects of internal and external contacts
Ability to present complex medical and reimbursement information to others and to be diplomatic and persuasive regarding health plan benefits, claims and eligibility
Ability to switch from one task or type of work to another as the business needs require
Ability to effectively prioritize work to meet strict timelines while maintaining quality and consumer centric focus
High school diploma or GED and a minimum 4 years’ experience in customer Service, Claims, or Clinical Services or equivalent combination of education and work experience

Job Responsibility

Responsible for all activities associated with appeal analysis, decision-making and closure
Appeal Intake – Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal. Document information in appropriate system
Appeal Analysis – Review claim coding and claim processing history, medical policy and reimbursement policies, regulatory and legal requirements, benefit contracts, and/or provider contracts. Collect and catalogue supporting documentation and formulate an appeal recommendation. Document information in appropriate system. Apply knowledge and experience to answer a variety of increasingly complex inquiries from members, providers, and provider representatives. Collaborate effectively with coding specialists, appeal nurses, physician reviewers, and others as necessary to reach timely decisions on appeals
Decision & Closure – Make non-clinical appeal determinations as permitted by department business processes and guidelines. Follow department’s processes to receive a clinical review and decision from licensed health professionals. Present complex cases to appeal panels, document decisions, communicate determinations to members, providers or their representatives. Document information in appropriate system(s)
External review process – Oversee set-up of appeals for external review organizations, including document collection and coordination, communication with all parties, and other responsibilities as an intermediary between the provider and the external review organization. Ensure external review information is documented in appropriate system. Prepares letters and cases for external review as needed. Implement external review decisions
Interpersonal and Communication – Provide information, education and assistance to members, providers, and their representatives. Facilitate the member’s or provider’s’ understanding of the appeal process and of the information necessary to effectively process an appeal. Be a courteous advocate to the member or provider when requesting supporting information. Work cooperatively and effectively across all business areas to resolve
Systems and data – Track appeals in appropriate systems and assist in the maintenance of files. Assist with compilation of reports on appeals, including trends, number of cases, decisions, suggestions for process improvement, types of appeals, and compliance with timelines
Support, apply and promote Provider or Member Appeal Policies & Procedures
Adhere to dependability, customer focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all work
Manage a defined caseload within department productivity and quality expectations and provide back up for other appeals staff

What we offer

Medical, dental, vision, life, disability, and other insurance plans
ESPP (employee stock purchase program)
401K program with company match after 12 months
HSA (Health Savings Account on the HDHP plan)
SupportLinc Employee Assistance Program (EAP) with up to 8 free counseling sessions
Corporate discount savings program
On-demand training program
Access to certification prep and a library of technical and leadership courses/books/seminars after 6+ months of tenure
Certification discounts and other perks to associations that include CompTIA and IIBA
Dedicated customer service team for Consultants

Fulltime

Claims Resolution Representative III

The Claims Resolution Representative III is responsible for working across the p...

Location

United States of America , Rochester

Salary:

19.62 - 26.49 USD / Hour

University of Rochester

Expiration Date

Until further notice

Requirements

Associate degree and 2 years of related relevant experience
or equivalent combination of education and/or experience
Excellent problem-solving skills
Excellent communication skills
Excellent customer service skills

Job Responsibility

Follows department policies and procedures and maintains and exercises comprehensive knowledge of insurance company billing requirements and regulations to research and resolve unpaid accounts receivable
Follows up on multi-faceted denials through review of remittances (EOBs), insurance correspondence, rejections
Research claims, identify problems, and take appropriate action to assure claim resolution
Responds to all billing-related inquiries from colleagues, departments, patients, and payors in a timely and professional manner
Communicates any missing/incomplete information to providers and department administrative support staff to ensure accurate billing
Communicates with insurance representatives through telephone calls, payer website, and written communication to ensure accurate processing of claims
Collaborate with appropriate departments to generate a detailed rational for appeals and grievances to the insurance companies
Keeps management informed of changes in billing requirements and rejection or denial codes as they pertain to claim processing and coding
Escalates system issues preventing claims submission and follow-up for review and resolution
Collaborates with Claim Edit Specialists and Patient Medical Billing Specialists assigned to pre claim WQ’s to identify opportunities for improvement in clean claims rate

Fulltime