Appeals Specialist

Quadax, Inc.; Middleburg Heights (OH); On-site; USD 45,000 - 65,000; Full time

Job summary

Quadax, Inc. seeks a denial management specialist to respond to insurance denials by preparing appeals and required documentation, and submitting them to payers within filing deadlines.

The role includes reviewing case history, gathering records, and coordinating external reviews to maximize reimbursement for patients. The position begins with on-site training for 3 months at Middleburg Heights, OH or Milan, OH, after which the role transitions to remote work.

Qualifications

• Four years of health insurance billing experience.
• Knowledge of managed care payer structures and rules.
• Ability to meet deadlines and maintain confidentiality.
• Detail oriented with strong written and verbal skills.
• Proficient with Excel and Word.

Responsibilities

• Review denials and EOBs for appeal filing information; gather missing information.
• Review case history, payer history, and state requirements to determine appeal strategy.
• Obtain patient and/or physician consent and medical records when required.
• Gather and fill out all special appeal or review forms.
• Create appeal letters, attach the materials, and mail them.
• Coordinate phone hearings with the insurer, patient, and physician.
• Comply with all appeal processes, SOPs, and documentation.
• Meet deadlines by completing tasks on the worklist and escalating when needed.
• Report requirements and denial trends to leadership.
• Participate in team meetings and share case details.
• Act as backup for incoming calls as needed.
• May undertake special projects as assigned.
• Maintain productivity and quality standards.

Skills

Denials management

Appeal letters

Insurance billing

Communication skills

Microsoft Excel

Microsoft Word

Attention to detail

Time management

Education

High School diploma/GED

Tools

Microsoft Excel

Microsoft Word

Job description

Overview: Respond to all assigned levels of denials by submitting appeal letters and required documentation to insurance companies within the appeal filing time limits. Submit external review requests and required documentation to the state within the filing time limits. Act as a patient advocate by identifying the path needed to obtain the maximum reimbursement under the insurance plan and work with the patient to get the denial overturned.

Remote: Although this position is listed as remote, the training period requires you working onsite 5 days/week for 3 months at our Middleburg Heights, OH or Milan, OH facilities before transitioning to remote.

Responsibilities:

• Review assigned denials and EOB’s for appeal filing information. Gather any missing information.
• Review case history, payer history, and state requirements to determine appeal strategy.
• Obtain patient and/or physician consent and medical records when required by the insurance plan or state.
• Gather and fill out all special appeal or review forms.
• Create appeal letters, attach the materials referenced in the letter, and mail them.
• Coordinate phone hearings with the insurance company, patient, and physician.
• Comply with all 1 st , 2 nd , 3 rd , and External Level Appeal process, system, and documentation SOP’s.
• Meet appeal filing deadlines by completing assigned worklist tasks in a timely matter and/or reporting to management when assistance is needed to complete the tasks.
• Report all insurance company or state requirements and denial trend changes to the Team Leader and Reimbursement Manager.
• Participate in team and appeal meetings by sharing the details of cases worked.
• Act as a backup on answering incoming telephone calls as needed.
• May undertake special projects assigned by the Team Leader or Reimbursement Manager.
• Ability to meet predetermined Productivity Goals based on the level of Appeal.
• Ability to meet Quality Standard in place (90% or greater).
• Other duties as assigned.

Qualifications:

• High School diploma or GED
• Minimum of four years health insurance billing experience
• Knowledge of managed care industry including payer structures, administrative rules, and government payers
• Proficient in all aspects of reimbursement
• Ability to maintain confidentiality
• Detail oriented
• Possess excellent written and verbal communication skills
• Able to establish priorities, work independently, and proceed with objectives without supervision.
• Proficient in using Microsoft Excel and Word

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws.

For further information, please review the Know Your Rights notice from the Department of Labor.