Appeals Analyst - PFS CCD Revenue Integrity - Sharp Corporate - Day Shift - Full Time

sharp; San Diego (CA); Sur place; USD 36 000 - 51 000; Plein temps

Résumé du poste

Sharp HealthCare in San Diego is seeking a billing and accounts management professional to appeal underpayments and manage payer issues within a multi-specialty medical group. The role emphasizes analytics, accurate rate loading, and timely appeals.

The candidate will handle underpayment trends, coordinate with payors, and maintain standardized letters while ensuring compliance with evolving regulations. Weekend work is not required; flexible start times are noted for the role.

Qualifications

• H.S. diploma or equivalent required.
• 5 years billing and 4 years accounts management in a multi-specialty medical group.
• Knowledge of benefits, managed care, and payer reimbursement procedures.

Responsabilités

• File appeals/PDRs on underpaid/denied claims and train staff.
• Analyze billing data and trends to improve revenue.
• Review payor EOBs, contracts, and payer websites to support appeals.
• Communicate with management on denial trends and actions.
• Ensure accurate quarterly, monthly, and yearly insurance rate data.

Connaissances

Analytical skills

Attention to detail

Communication

Team player

MS Excel

Medical terminology

Formation

H.S. Diploma or Equivalent

Bachelor's Degree in finance, business or economics

Outils

MS Excel

Description du poste

Hours

• Shift Start Time: Variable
• Shift End Time: Variable
• AWS Hours Requirement: 8/40 - 8 Hour Shift
• Additional Shift Information: Flexible start time between 5 - 7 AM
• Weekend Requirements: No Weekends
• On-Call Required: No
• Hourly Pay Range (Minimum - Midpoint - Maximum): $26.320 - $32.890 - $36.830

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do

To appeal for underpayments compared to contract rates. Escalate payer contractual issues to payers and management of Sharp.

Required Qualifications

• H.S. Diploma or Equivalent
• 5 Years experience in all areas of billing and 4 years accounts management experience in a multi specialty medical group.

Preferred Qualifications

• Bachelor's Degree with emphasis in finance, business administration or economics.
• Experience in resolving difficult underpayment/denial issues, categorizing inventory into underpayment reasons, identifying root cause, recognizing trends and clearly and persuasively articulating issues to payor.

Essential Functions

• Financial analysis and reporting
• Successfully file appeals/PDR's on non-clinical underpaid/denied claims and maintain standardized letters for use in training of account analysts. Required to explain new legislation impacting underpayments/denials etc.
• Trend and identify underpayment/denial issues for training purposes with the goal of mitigating future underpayments/denials. Work on ad hoc reports to reconcile inventory or identify opportunities for increased revenue collection using reporting tools.
• Assure the current quarterly, monthly, yearly insurance rates are obtained and loaded into the Contract Underpayment tool for accurate expected rate analyzation.
• Productivity
• Focus appeal efforts on underpayments/denials with highest propensity for recovery, considering Payor appeal timeframes, Payor contract reimbursement, underpaid/denial reason, facility, patient type.
• Regularly meet projected collection goals and appeal productivity standards. Maintains excellent communication with supervisor/management and high accuracy of work.
• Quality
• Using underpayment tool and billing software, review payor EOB, contract, payor website, etc. necessary to support basis for appeal. Must be cross-trained and file appeals outside assigned payor mix in the absence of fellow team member.
• Commence direct follow up action on appeals filed according to time frames.
• System integration
• Provide ongoing training/feedback to account analysts to improve success rate on initial appeals/PDR's filed.
• Participate in meetings with Management, to review and consult on appeal denial trends to determine next step/action plan towards resolution.
• Other duties, as assigned.

Knowledge, Skills, and Abilities

• Must possess strong analytical and mathematical skills to resolve underpayment inventory.
• Must be detail oriented and possess a diligent work ethic.
• Strong communication and excellent interpersonal skills.
• Team Player.
• Knowledge of benefits, covered services, Managed Care (contract payor) reimbursement and billing procedures of both government and non-government insurance programs.
• Familiarity with current regulations of affiliated payors.
• Familiarity with MS excel required. Knowledge of ICD-9 and CPT-4 codes, and basic medical terminology.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class