Appeals Professional/Dispute Resolution Review - Reading

Healthcare Quality Strategies, Inc.; Pennsylvania; Remote; USD 75,000; Full time

Job summary

A healthcare organization in Pennsylvania seeks an Appeals Professional to handle healthcare claims appeals and dispute resolution. The role requires an LPN or RN license, and significant experience in clinical processing and decision-making. Responsibilities include evaluating evidence, providing determinations, and mentoring staff. This position allows for remote work but requires applicants to be based in Pennsylvania.

Qualifications

• Unencumbered LPN or RN Licensure required.
• 5 years clinical experience with 3 years in healthcare claims processing or review needed.
• Experience in Medicare appeals is a plus.

Responsibilities

• Reviews medical records and writes clear and impartial decisions.
• Makes independent decisions based on evidence and regulations.
• Conducts research on federal regulations and makes sound decisions.

Skills

Research techniques

Medical terminology

Understanding of healthcare coverage and payment rules

Multitasking

Effective communication

Excel proficiency

Word proficiency

Education

Current LPN or RN Licensure from an accredited college or university

AAPC or AHIMA Certification

Associate's degree or technical/trade school diploma in medical billing or coding

Job description

Appeals Professional/Dispute Resolution Review 111 (Clinical)

FT (40 hours/week) – Remote Work Environment – APPLICANTS MUST BE BASED IN PA

Salaried Non-Exempt: $75,000 annually

Reviews documentation requirements and evidence for appeals and/or rebuttals of healthcare claims appeals, enrollment denials, revocation and or suspension. Performs complex (senior-level) work. Provides dissatisfied patients/beneficiaries and/or providers with the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. Provides an independent second level determination/dispute resolution based on the documentation, facts, laws, regulations and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

• Reviews medical records/case files, writes a decision that is clear, concise, and impartial and supports the determination made, and documents the reviews
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy
• Responds to and ensures that all issues raised by the beneficiary, representative, supplier, and provider have been addressed
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures
• Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision
• Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures
• Plans responses to statistical analysis challenges with assistance from statisticians
• Attends meetings and participates in workgroups at the direction of management
• Conducts quality reviews, as needed
• Serves as a subject matter expert
• Mentors and/or trains staff
• May conduct quality reviews and audits
• Participates in special projects and performs other duties as assigned

Education

• Current, unencumbered LPN or RN Licensure from an accredited college or university (Associate’s degree/Bachelor’s degree) required
• AAPC or AHIMA Certification and/or a minimum of Associates Degree or technical/trade school diploma in medical billing or medical coding a plus

Experience:

• 5 years clinical experience with a minimum of 3 years experience inclusive of healthcare/health plan claims processing, utilization review, medical billing, medical coding necessary
• Experience in Medicare appeals, medical review, clinical or other related experience in a healthcare setting

Required Skills and Abilities

• Research techniques
• Medical terminology
• Understanding of healthcare coverage and payment rules
• Understanding of healthcare regulations, claims administration, and medical review processes
• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and
• reviewing documents for clarity and consistency
• Prioritizing and organizing work assignments
• Multitask and meet deadlines
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities
• Excel and Word Proficiency a must

Physical Demands:

The conditions herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions.

Primary functions require sufficient physical ability and mobility to work in an office setting; to sit for prolonged periods of time; to occasionally stand, stoop, bend, kneel, crouch, reach, and twist; to operate office equipment requiring repetitive hand movement and fine coordination including use of a computer keyboard and to verbally communicate to exchange information.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

For immediate consideration, please apply via the HQSI Careers Page at:www.hqsi.org > Careers > Current Employment Opportunities

EOE: Minorities/Females/Disabled/Veterans

Healthcare Quality Strategies, Inc. is Equal Opportunity, Affirmative Action Employer and an Alcohol/Drug Free Workplace

Healthcare Quality Strategies, Inc. is an E-Verify Employer