Job Purpose:
The Coding Appeals Specialist is responsible for handling denied claims and associated tasks to resolve unpaid claims. The Coding Appeals Specialist is also responsible for submitting claim reconsideration requests, handling appeals, and correcting claims as needed.
Primary Duties and Responsibilities:
- Investigates and handles denied claims and resolves unpaid claims
- Creates and submits claim reconsideration requests, appeals, and corrected claims
- Monitors resolution and payment from participating insurance carriers
- Communicates with insurance companies for clarification of denials and status on appeal requests
- Communicates with manager and billing staff payer specifications and/or policies regarding claims and payer denial trends
- Researches and documents medical compliance issues as well as policy and procedures of government and private payer health plans related to billing
- Reviews industry information including but not limited to regulatory bulletins and payer portals for process changes, communicating information with team
- Documents all actions and communications in claim logs
Competencies:
- Service: We align our actions and decision making with the organization’s guiding platform keeping our patients at the center of all we do.
- Change Agent: We support and contribute to positive change in the organization.
- Communication and Interpersonal Relations: We communicate honestly and with compassion to build connections with our patients and each other.
- Effectiveness: We take ownership of work, doing the right thing for our customer and doing it well.
Organizational Culture:
All OrthoIllinois employees focus on service by putting the mission, vision, and value statements into practice and using the guiding principles of Compassion, Respect, Trust, Integrity, Innovation, Education Fiscal Responsibility, Practice Independence, Accountability, and Empowerment to direct their interactions and decision making. Employees promote and model the service standards to create lasting impressions, extraordinary moments, exceptional on-stage experiences, and meaningful and compassionate connections.
Education and Experience Requirements:
- High School Diploma or GED required
- A minimum of five years of experience in medical claim management
- Advanced understanding of medical terminology
- Advanced understanding of commercial insurance, Medicare and Medicaid billing and appeals process
- Advanced understanding of CPT, ICD 10, HCPCS coding requirements; medical coding certification preferred
- Advanced working knowledge of EHR and insurance and hospital portals
- Basic working knowledge of Microsoft and Google Suites
Environmental/Working Conditions:
Working environment is in an office/clinic setting.
Physical/Mental Demands:
- Sit, stand, walk, stoop or kneel, crouch or crawl, and climb stairs for long periods of time
- Requires lifting, carrying and/or moving objects in a manner consistent with most office environments (generally, no more than 10 pounds on a frequent basis and 20 pounds on an occasional basis)
- Possess full range of motion in shoulders and arms, including reaching above or below the shoulder
- Finger dexterity; the ability to twist hands/wrists repetitively
- Vision (e.g., depth perception, color vision, strong vision up close), hearing (e.g., high pitch sounds, soft or distant sounds)
This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.
