Appeals Professional/Dispute Resolution Reviewer/Case Analyst

Healthcare Quality Strategies, Inc.; Ocala (FL); Remote; USD 55,000; Full time

Job summary

A leading company in healthcare is seeking an Appeals Professional/Dispute Resolution Review/Case Analyst. This full-time remote role involves reviewing healthcare claims, making independent decisions, and ensuring compliance with regulations. Ideal candidates will have a strong background in healthcare billing and excellent communication skills. Join a supportive team that values integrity and professionalism in a dynamic work environment.

Qualifications

• 5-10 years of related healthcare billing experience may substitute education.
• Minimum of 3-5 years in healthcare claims processing or medical billing.

Responsibilities

• Review documentation for appeals and rebuttals of healthcare claims.
• Evaluate medical records and write clear decisions.
• Conduct research using federal regulations and medical standards.

Skills

Research techniques

Medical terminology

Communication

Logical reasoning

Problem-solving

Integrity

Education

Certification from AAPC or AHIMA

Associate's Degree

Tools

Excel

Word

Job description

Healthcare Quality Strategies, Inc. - Appeals Professional/Dispute Resolution Review / Case Analyst

Position Type: Full-Time (40 hours/week) – Remote Work Environment
Location: Applicants must be based in FL
Salary: $55,000 annually (Salaried Non-Exempt)

Job Responsibilities

• Review documentation requirements and evidence for appeals and rebuttals of healthcare claims, enrollment denials, revocations, and suspensions.
• Evaluate medical records and case files, and write clear, concise, and impartial decisions supporting the determinations made.
• Make independent, sound decisions based on medical evidence, statutes, regulations, rulings, and policies.
• Respond to and address issues raised by beneficiaries, representatives, suppliers, and providers.
• Provide fair decisions based on current evidence, regulations, policies, and procedures.
• Conduct research using federal regulations, policies, standards of medical practice, manuals, literature, and other resources to support accurate decisions.
• Stay updated on changes in regulations, medical and healthcare practices, policies, and procedures.
• Participate in special projects and perform other duties as assigned.

Qualifications

Education:

• Certification from AAPC or AHIMA, or a minimum of an Associate's Degree or technical/trade school diploma in medical billing or coding.
• 5-10 years of related healthcare billing experience may substitute formal education or certification.

Experience:

• Minimum of 3-5 years in healthcare claims processing, utilization review, medical billing, or coding.

Skills and Abilities

• Research techniques and medical terminology proficiency.
• Understanding of healthcare coverage, payment rules, regulations, claims processing, and medical review procedures.
• Excellent communication skills, both verbal and written.
• Ability to prioritize, organize, multitask, and meet deadlines.
• Logical reasoning and problem-solving skills.
• Decision-making aligned with business objectives.
• Integrity, confidentiality, and adherence to ethical standards.
• Proficiency in Excel and Word.

Note: This job description is not exhaustive and duties may change or new responsibilities may be assigned at any time.

Equal Opportunity Employment

Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants, prohibiting discrimination and harassment based on race, color, religion, age, sex, national origin, disability, genetics, veteran status, sexual orientation, gender identity, or other protected characteristics.

Application Process

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 an Equal Opportunity, Affirmative Action Employer and maintains an Alcohol/Drug-Free Workplace. We are also an E-Verify Employer.