Appeals Specialist I

Job Summary

The Appeals Specialist I is responsible for reviewing patient accounts denied for insurance reimbursement or paid incorrectly and following through with the appeal process to secure payment. This role requires effective communication, thorough research of claims, and collaboration with financial service units to resolve discrepancies and improve reimbursement rates.

As an Appeals Specialist I at Community Health Systems (CHS) - SSC Sarasota, you’ll play a vital role in supporting our purpose to help people get well and live healthier by providing safe, quality healthcare, building enduring relationships with our patients, and providing value for the people and communities we serve. Our team members enjoy a robust benefits package including medical insurance, dental insurance, vision insurance, PTO, 401K, sick time, holidays, and bonus where eligible.

Essential Functions:

• Reviews denied claims and incorrect payments, initiating the appeals process to secure appropriate reimbursement from insurance carriers.
• Communicates with patient financial service units to ensure accurate processing of accounts, including revisions and payment schedules.
• Collaborates with appeals representatives to meet departmental demands, demonstrating flexibility and teamwork to support workload management.
• Researches and resolves claim discrepancies, including underpayments, incorrect denials, and incomplete charges, using knowledge of revenue codes, HCPC codes, and insurance guidelines.
• Analyzes explanation of benefits (EOBs) from various carriers to identify and address payment discrepancies, ensuring compliance with insurance contracts and guidelines.
• Responds to inquiries from other departments and insurance carriers, providing timely updates on claim status, additional documentation needs, and resolution strategies.
• Works closely with the Managed Care Department to address ongoing issues with contracted insurance companies, supporting improvements in claim management.
• Maintains accurate logs and reports of outstanding appeals, providing regular updates to leadership on claim status and outcomes.
• Assists case workers with pre-certification and authorization issues related to appeals, providing necessary data for resolving inpatient/clinical denials.
• Performs other duties as assigned.
• Complies with all policies and standards.
• This is a remote position.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Required:
  • Education: H.S. Diploma or GED
  • Experience: 1-3 years of experience in claims processing, healthcare billing, or revenue cycle management
• Preferred:
  • Education: Associate’s Degree in Healthcare Administration, Business, or a related field

Knowledge, Skills and Abilities:

• Basic knowledge of medical billing, coding systems, and insurance claim processes.
• Strong communication skills for interacting with insurance carriers, patient financial service units, and other departments.
• Detail-oriented, with strong organizational and time management skills to manage a high volume of appeals.
• Proficiency in using healthcare billing software and Google Suite.

We know it’s not just about finding a job. It’s about finding a place where you are respected, valued and where your work is purposeful and fulfilling. A place where your talent is recognized, professional development is encouraged and career advancement is possible.

The Sarasota SSC operates in support of our hospitals and patients and our commitment is to provide them with exemplary revenue cycle services defined by outstanding customer service and superior revenue cycle performance. SSC Sarasota supports facilities located primarily in Florida, Georgia, Indiana, and Pennsylvania.

Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 71 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.

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Originally posted on Himalayas