Appeals Writer Analyst

Talkpush; Taguig; On-site; PHP 420,000 - 540,000; Full time

Job summary

Talkpush is seeking a qualified professional to validate dispute reasons after EOB review and to escalate payment variance trends to NIC management. The role includes generating appeals for denied or underpaid claims and coordinating with clinical and billing teams to ensure accurate coding.

The candidate will follow payer guidelines for submissions, research contract terms, and prepare documentation for IMaCS adjudication issues while ensuring proper routing of accounts for resolution.

Qualifications

• Intermediate understanding of Explanation of Benefits form (EOB) and Managed Care.
• Contracts, Contract Language and Federal and State Requirements.
• Intermediate knowledge of hospital billing form requirements (UB-04).
• ICD-9, HCPCS/CPT coding, and medical terminology knowledge.
• Microsoft Office (Word, Excel) skills.
• Advanced business letter writing with correct grammar and punctuation.

Responsibilities

• Validate denial reasons and ensure coding in DCM is accurate; coordinate with CRC for consultations or referrals.
• Generate an appeal based on dispute reasons and contract terms; include online reconsiderations.
• Follow payer guidelines for appeals submissions.
• Escalate exhausted appeal efforts for resolution.
• Research contract terms and prepare supporting documentation for appeals and IMaCS adjudication issues.
• Code the DCM system appropriately and route accounts, based on research and corrective actions.
• Escalate denial or payment variance trends to NIC leadership.

Skills

EOB/Managed Care knowledge

Contracts & language comprehension

UB-04 coding

ICD-9/HCPCS/CPT coding

Microsoft Word

Microsoft Excel

Professional writing/grammar

Tools

Microsoft Word

Microsoft Excel

Job description

JOB SUMMARY

Responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to NIC management, and generating appeals for denied or underpaid claims.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Validate denial reasons and ensures coding in DCM is accurate and reflects the denial reasons. Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary,
2. Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations. %
3. Follow specific payer guidelines for appeals submission
4. Escalate exhausted appeal efforts for resolution
5. Work payer projects as directed
6. Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet-enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments.
7. Perform research and makes the determination of corrective actions and take appropriate steps to code the DCM system and route account appropriately. %
8. Escalate denial or payment variance trends to the NIC leadership team for payor escalation

KNOWLEDGE, SKILLS, ABILITIES

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 essential functions.

• Intermediate understanding of Explanation of Benefits form (EOB), Managed Care
• Contracts, Contract Language and Federal and State Requirements
• Intermediate knowledge of hospital billing form requirements (UB-04)
• Intermediate understanding of ICD-9, HCPCS/CPT coding, and medical terminology
• Intermediate Microsoft Office (Word, Excel) skills
• Advanced business letter writing skills to include correct use of grammar and punctuation