Academy of Managed Care Pharmacy
Appeal Support Specialist - Denial Resource Center
Academy of Managed Care Pharmacy, Dallas, Texas, United States, 75215
JOB SUMMARY
The Denial Resource Center Appeal Support Specialist is responsible for ensuring that complete and accurate appeals of denied claims are submitted to the payer in a timely manner according to guidelines set forth by the payer. The Appeal Support Specialist processes submissions of reconsiderations, redeterminations, appeals, resubmissions of previously submitted appeals, submissions of State Complaint letters, legal submissions to the Administrative Law Judge, as well as requests for Coordination of Benefits or Patient Consent letters to the patient. The Appeal Support Specialist also serves as an appeal writer for non-clinical appeals that meet specific criteria.
ESSENTIAL FUNCTIONS OF THE ROLE
Ensures that all documentation submitted to the payer is true and accurate, any necessary forms are completed, and all documentation is submitted to the appropriate provider portal, payer address or fax number. Ensures that submissions are sent in a manner so that they are received by the payer prior to the established deadline.Completes resubmissions of previously submitted redeterminations and appeals. Reviews notation on the account to determine the correct manner for resubmission, compiles a resubmission letter including details of previous submissions and resubmits the appeal to the payer.Performs non-clinical appeals on low dollar, outpatient, pre-auth denials. Reviews the patient’s records to verify the reason for the denial and if authorization was required and/or obtained. Completes an appeal letter with details of the denial and information to support overturning the claim. Pulls medical records and any supporting documentation from previous hospitalizations, episodes of care within a series, or physician office records to support their appeal.Compiles documentation to submit on accounts that have been identified through Insurance Ops review and are escalated to the Managed Care Legal team.Requests complete medical records and notarized affidavits from the Health Information Management department as needed.Processes all incoming correspondence and ensures that it is distributed to the correct teams. Ensures that all outgoing correspondence is taken to the mail room daily.Appropriately documents submission information and appeal findings into the accounts receivable system and ensures that all accounts are accurately transferred to the next team once complete.Participates in pertinent meetings and huddles to share trends identified with leadership.
KEY SUCCESS FACTORS
Knowledge of office procedures.Able to maintain the confidentiality of sensitive and confidential information obtained through the course of completing assignments.Skilled in document management, including sorting and filing techniques, and records retention to maintain accurate records.Able to communicate thoughts clearly; both verbally and in writing.Must be able to read, write and follow instructions and flow chart protocols.Able to maintain a calm and helpful attitude, even under times of stress, and take appropriate and reasonable steps to resolve issues.Able to work carefully, with a high attention to detail.Advanced computer skills, including but not limited to: typing, information security, electronic medical documentation, hand held scanning and email.Proficient with MS Office suite including Word, Excel, PowerPoint.
BENEFITS
Our competitive benefits package includes the following:Immediate eligibility for health and welfare benefits401(k) savings plan with dollar-for-dollar match up to 5%Tuition ReimbursementPTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level.
QUALIFICATIONS
EDUCATION - H.S. Diploma/GED EquivalentEXPERIENCE - 2 Years of Experience
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The Denial Resource Center Appeal Support Specialist is responsible for ensuring that complete and accurate appeals of denied claims are submitted to the payer in a timely manner according to guidelines set forth by the payer. The Appeal Support Specialist processes submissions of reconsiderations, redeterminations, appeals, resubmissions of previously submitted appeals, submissions of State Complaint letters, legal submissions to the Administrative Law Judge, as well as requests for Coordination of Benefits or Patient Consent letters to the patient. The Appeal Support Specialist also serves as an appeal writer for non-clinical appeals that meet specific criteria.
ESSENTIAL FUNCTIONS OF THE ROLE
Ensures that all documentation submitted to the payer is true and accurate, any necessary forms are completed, and all documentation is submitted to the appropriate provider portal, payer address or fax number. Ensures that submissions are sent in a manner so that they are received by the payer prior to the established deadline.Completes resubmissions of previously submitted redeterminations and appeals. Reviews notation on the account to determine the correct manner for resubmission, compiles a resubmission letter including details of previous submissions and resubmits the appeal to the payer.Performs non-clinical appeals on low dollar, outpatient, pre-auth denials. Reviews the patient’s records to verify the reason for the denial and if authorization was required and/or obtained. Completes an appeal letter with details of the denial and information to support overturning the claim. Pulls medical records and any supporting documentation from previous hospitalizations, episodes of care within a series, or physician office records to support their appeal.Compiles documentation to submit on accounts that have been identified through Insurance Ops review and are escalated to the Managed Care Legal team.Requests complete medical records and notarized affidavits from the Health Information Management department as needed.Processes all incoming correspondence and ensures that it is distributed to the correct teams. Ensures that all outgoing correspondence is taken to the mail room daily.Appropriately documents submission information and appeal findings into the accounts receivable system and ensures that all accounts are accurately transferred to the next team once complete.Participates in pertinent meetings and huddles to share trends identified with leadership.
KEY SUCCESS FACTORS
Knowledge of office procedures.Able to maintain the confidentiality of sensitive and confidential information obtained through the course of completing assignments.Skilled in document management, including sorting and filing techniques, and records retention to maintain accurate records.Able to communicate thoughts clearly; both verbally and in writing.Must be able to read, write and follow instructions and flow chart protocols.Able to maintain a calm and helpful attitude, even under times of stress, and take appropriate and reasonable steps to resolve issues.Able to work carefully, with a high attention to detail.Advanced computer skills, including but not limited to: typing, information security, electronic medical documentation, hand held scanning and email.Proficient with MS Office suite including Word, Excel, PowerPoint.
BENEFITS
Our competitive benefits package includes the following:Immediate eligibility for health and welfare benefits401(k) savings plan with dollar-for-dollar match up to 5%Tuition ReimbursementPTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level.
QUALIFICATIONS
EDUCATION - H.S. Diploma/GED EquivalentEXPERIENCE - 2 Years of Experience
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