Appeals Analyst Resume Samples

Description :

1. Reviewed & Audited all Medicare Denial claims in Millbrook Analyze & Review Denial status and assign denied claims with the proper status.
2. Input & Documented all Denial correspondence in Excel.
3. Reviewed & understood Medicare and other EOB's Analyze denial trends and document specific or repetitive occurrences.
4. Gathered information from Medicare Regions concerning how? the claim is being denied.
5. Assisted team members with information on Customer benefit plans thru CSI.
6. Assisted team members with information on how a CMN was submitted electronically, and if any corrections are needed.
7. Researched appealing applicants' information included in the Appeal Packet.

Experience

5-7 Years

Level

Executive

Education

GED

Description :

1. Reviewed all Road Home policies, procedures, and calculations associated with the Appeal Packet.
2. Communicated with all other Road Home Departments as needed to seek clarification on calculations and policies.
3. Communicated with applicants to provide information on the process.
4. Maintained and adhered to timelines and deadlines attached to the Appeal Packet.
5. Collected, analyzed, and reported QA/QC data for distribution to senior management and the customer.
6. Analyzed data related to performance metrics and prepare summary reports.
7. Wrote, edited, and prepared management and technical presentations and support their delivery.

Experience

2-5 Years

Level

Executive

Education

High School Diploma

Description :

1. Investigated medical necessity appeal inquiries and implemented resolution according to the Georgia Department of Community Health (DCH) and the National Committee for Quality Assurance (NCQA) guidelines and timeframes.
2. Served as a health plan subject matter expert for appeal and denial work processes.
3. Updated departmental policies and procedures in compliance with corporate and state contractual guidelines.
4. Developed and implemented a denial and appeal process, including a comprehensive database for use in auditing and reporting.
5. Completed and verified the entry of identified data into various computer software applications (IDX) to ensure the availability of information for healthcare professionals and providers in the provision of care and validate the appeal request and prepared Level 2, Level 3, and expedited appeals for medical physician review.
6. Contacted providers for supporting clinical documentation regarding claims when necessary, to make a determination for an appeal.
7. Prepared notification of acknowledgment and resolution correspondence to members, representatives, and providers.

Experience

2-5 Years

Level

Junior

Education

Bachelor Of Science

Description :

1. Researched complaints and grievances appeals submitted by members and chiropractic and physical medicine and rehabilitation providers regarding denial of benefits, quality of care, policies, procedures, etc.
2. Reviewed medical documentation and provides clinical and claim expertise on appealed claims.
3. Prepared appropriate clear and concise communication, acknowledgment letters, responses to appeals, and /or grievances, and related correspondence to consumer clients, clinicians, and claim operations staff summarizing the appeal review determination.
4. Met deadlines for the completion of appeals as determined by the member's health plan.
5. Monitored and tracked the number of appealed claims appeals.
6. Adhered to the highest quality and ethical standards when reviewing appealed claims and making determinations.
7. Ensured integrity of the claim appeal process and ensures compliance with state and federal legislation.

Experience

2-5 Years

Level

Executive

Education

BA In Mass Communications

Description :

1. Coordinated response activities between appropriate departments, conduct a necessary investigation by reviewing telecommunication tapes of related and pertinent calls, as well as any documentation or claims submitted by members or providers, and any other related documentation, i.e., medical policies and contracts, to ensure that all appeals and grievances are thoroughly researched and sends written resolution letter to appropriate party on first level standard appeals and all levels of administrative appeals and grievances within the required time frame.
2. Sent out acknowledgment letters on all levels of administrative appeals and grievances within the required timeframe to notify the requestor that we have received their appeal request and to advise him/her of the timeframe within which the appeal will be resolved.
3. Presented and/or prepares 2nd level cases with all relevant case data.
4. Coordinated the 2nd level Appeals and Grievance committee meetings including contacting committee members to ensure adequate representation fro all relevant areas are present.
5. Prepared appeals packets so that committee members have the documentation needed to make a well-informed decision.
6. Minuted are taken for each case presented for documentation purposes and to assist in completing the final resolution letters.
7. Maintained knowledge of current company policies and procedures, accreditation guidelines, and state and federal laws to ensure compliance.

Experience

2-5 Years

Level

Junior

Education

GED

Description :

1. Experienced in audit support to include compiling various documents and data for outside state audit companies.
2. Knowledged in researching and interpreting plan benefit documents.
3. Communicated with appropriate parties regarding appeals and grievance issues, implications, and decisions.
4. Analyzed and identified trends for all appeals and grievances.
5. Researched and resolved written Department of Insurance complaints.
6. Met with members face-to-face or take testimony via telephone in order to comply with Healthcare Reform regulations for file review and presentation.
7. Handled other projects as assigned, such as Imaging Auto Work Distribution and the Administrative Appeals email box, as needed to help the department reach goals and maintain compliance.

Experience

2-5 Years

Level

Executive

Education

GED

Description :

1. Responsible for examining and evaluating previously paid moderate to complex managed care contracts and fee schedules to determine and generate proper reimbursement.
2. Served as the liaison between the medical claim appeals department and contracting entities to identify and submit the under allowed medical appeals.
3. Performed a detailed review of all contractual, billing, registration, and posting errors submitted.
4. Created reports to track for accuracy and to determine appropriate remedies.
5. Responsible for keeping abreast of rules, regulations, and contracts that are continuously changing to ensure that policy changes that may affect provider reimbursement are carried out without error or delay.
6. Demonstrated an in-depth understanding and expertise of complex problems involving a wide range of standard and non-standard situations involving health care reimbursement.
7. Independently identified and brought to leadership's attention any unusual or new medical procedures or billing anomalies identified during the review.

Experience

2-5 Years

Level

Junior

Education

Bachelor Of Science

Description :

1. Organized and compared bills/rates with appropriate fee schedules to determine whether additional payment is due or if the recovery of the overpayment is necessary.
2. Maintained strict confidentiality for protecting personal health information and prevent violation of HIPPA regulations.
3. Served as a job shadow mentor for new hires.
4. Prepared training manuals.
5. Communicated Physician's medical necessity decision to the members, representatives, and providers.
6. Reviewed inquiries to determine if they met the definition of appeal or grievance.
7. Investigated appeal by requesting all related documents.

Experience

5-7 Years

Level

Executive

Education

GED

Description :

1. Claimed Processor Call Coach Complaints and Appeals Analyst San Diego, CA Responsible for managing resolution complaint/appeal scenarios for all Products.
2. Ensured timely, customer-focused response to complaints and appeals.
3. Reviewed and adjudicated claims in accordance with claims processing guidelines.
4. Handled customer service inquires and problems via telephone, internet, or written correspondence.
5. Acted as a subject matter expert by providing training, coaching, or responded to complex issues.
6. Able to utilize reference manuals Knowledge of medical terminology and or related work experience Thorough knowledge of all Insurance products, PPO, and HMO based Ability to operate a personal computer, copier, fax and multiply line phones Technical knowledge of CPT, HCPC, and ICD-9 coding.
7. Completed and submitted said appeals to the insurance companies.

Experience

5-7 Years

Level

Junior

Education

High School Diploma

Description :

1. Reviewed all Information included in complete Appeals Packets and Appeal Determination Report.
2. Implemented required appeal case changes as outlined in the Appeals Determination Report, including updating calculations based on documentation to support any changes and in accordance with the policies and procedures of The Road Home Program.
3. Served as point of contact for applicant awarded corrective action via telephone and e-mail.
4. Entered summary of corrective actions into Issue Tracker.
5. Transferred information to the assigned point of contact to proceed with the pre-closing or second disbursement process.
6. Researched information related to formal Road Home appeals by carrying out the following duties: Reviewed all information included in assigned Appeal packets, eGrants, and Issue Tracker.
7. Reviewed all Road Home policies, procedures, and calculations associated with the Appeals packet, directly and indirectly.

Experience

2-5 Years

Level

Junior

Education

GED