The main role of an Appeals Representative is to log, process, and track the appeals and grievances of customers. While the job duties vary based on the type of the organisation, the following are certain common duties listed on the Appeals Representative Resume – reviewing the patient record, conducting patient research, building case files for every received grievance, reporting to the supervisors or manager-in-charge, searching for evidence to support appeal arguments, and taking regulatory actions as needed.
To become one, possessing the following skills are considered essential – collecting and researching skills, good knowledge of HIPAA guidelines, the ability to take support affirmative actions, demonstrable amount of accuracy and thoroughness, and strong communication skills. Education requirements vary from employer to employer but most often a degree in the field of hospital and business management is seen on resumes. Some employers prefer a nursing degree.
Headline : Six years assisting in the design and administration of a multiple-tiered system of grant program designed to impact gaps and concerns as detailed in the county and regional plans for improving child care programs throughout 7 counties of the 17-county Central Regional Key of the Pennsylvania state-wide early care and education initiative.
Skills : Additional Certifications- HIPPA, Medical Terminology, Compliance Ethics, and Fraud, Waste and Abuse.
Description :
Conducted a review of Medicare Part B claims on services questioned on appeal by the provider or facility of the service, beneficiary, Centers for Medicaid and Medicare Services (CMS) or other interested parties.
Requested may be either written or telephonic.
Rendered an independent decision based on research of the initial claim processing activity, documented procedures and policies, and information supplied with the appeal request.
Initiated a response to the inquirer and appropriate parties to the appeal in the form of an adjustment to payment, refund request for over payment or written correspondence when upholding the processing of the service.
Worked within multiple computer applications, such as: the Standard Medicare System (MCS), Fiscal Intermediary Standard System (FISS), and Microsoft Windows applications.
Communicated effectively.
Displayed effective telephone and written communication skills while responding timely to Medicare inquiries that constitute an appeal or reopening of an initial claim determination.
Experience
5-7 Years
Level
Executive
Education
B.A.
Appeals Representative Resume
Objective : Appeals Representative is responsible for handling all appeals, including appeals from the Board of Directors and internal investigations. This includes handling all appeals of cases that have been filed by external parties, as well as handling all internal appeals.
Skills : Microsoft Word, Microsoft Office, Microsoft Excel, Data Entry, Customer Service, Computer .
Description :
Reviewed incoming appeals to make Re determination and/or Reopening Decisions.
Reviewed the Standard Operations Procedures (SOP) to stay current on Centers for Medicaid and Medicare Services (CMS) regulations to ensure the re determinations were properly completed.
Ran aged cases to ensure that they did not roll to 60 days.
Indexed appeals to later have appeals adjusted for payment.
Used Case 360, web based, to obtain daily work and process the indexing portion of the appeals process.
Used the TPX/MCS to research information to ensure information is correct on Case 360 so appeals representatives, accounts receivable representatives and other departments to correctly process the providers appeals.
Researched electronic files, imaged records and/or accessing the appropriate external systems, reading and interpreting processing guidelines determining the accuracy of the original claim determination and taking the necessary actions to finalize the case file.
Experience
2-5 Years
Level
Junior
Education
GED
Appeals Representative Resume
Summary : Appeals Representative is responsible for Initiating letters to be mailed to all parties of the appeals decision Initiate a response to the inquirer and appropriate parties to the appeal in the form of an adjustment to payment, refund request for over payment or written correspondence when upholding the processing of the service, Working with multiple computer applications such as the Standard Medicare System (MCS), Fiscal Intermediary Standard System (FISS), and Microsoft Windows applications.
Responsible for the following: Conduct a review of Medicare Part A /B claims on services questioned on appeal by the provider or facility of the service, beneficiary, Centers for Medicaid and Medicare Services (CMS) or other interested parties.
Requested may be either written or telephonic.
Initiated a response to the inquirer and appropriate parties to the appeal in the form of an adjustment to payment, refund request for over payment or written correspondence when upholding the processing of the service.
Worked within multiple computer applications, such as: the Standard Medicare System (MCS), Fiscal Intermediary Standard System (FISS) Ability to make independent decision relating to claims processing accuracy relying on various on-line reference tools.
Responded timely to Medicare inquiries that constitute an appeal or reopening of an initial claim determination.
Analysed and rendered determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication.
Performed claim correction activity of the initial claim determination when an additional payment or a reduction in payment correction is necessary.
Experience
7-10 Years
Level
Management
Education
MS
Appeals Representative Resume
Objective : Appeals Representative who goes above and beyond basic administrative tasks and takes on multiple projects at once. Excellent work ethic and strength in boosting company morale.
Skills : Revenue Cycle Management, Business Relationship Hiring And Firing, Interviewing Skill, Leadership.
Description :
Reviewed incoming requests and determined the nature of Appeal.
Verified membership and gathered all pertinent documents for appeal.
Worked with the Appeals Pharmacists to complete the review.
Precisely completed appropriate claims paperwork, documentation and system entry.
Verified patients' eligibility and claims status.
Examined, categorised and sorted incoming documents.
Experience
2-5 Years
Level
Executive
Education
GED
Appeals Representative Resume
Objective : Experienced Appeals Representative professional seeks a position within a diverse organisation that allows vast opportunities for growth and advancement professionally and personally.
Provided expertise and or general support to teams in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances.
Analysed and identified trends in appeals and grievances.
Researched and resolved written Department of Insurance complaints and complex or multi-issue provider complaints.
Analysed and researched how claims were processed and denied.
Obtained/identified contract language and processes/procedures relevant to the appeal process.
Determined where specific appeals or grievances should be handled and route to the appropriate department(s).
Ensured that all members obtained a full and fair review of their appeal or grievance.
Experience
2-5 Years
Level
Executive
Education
Bachelors Of Science
Appeals Representative Resume
Summary : Appeals Representative is responsible for Reviewing Medicare Part B appealed claims from providers and beneficiaries for reconsideration for allowance of covered service(s) and payment, Reprocessing claims on TAP line from providers by reopening claims needing to make corrections on finalised claims containing data errors or errors of omission, Maintaining daily logs and working suspensions and ageing macros to ensure claims reprocess correctly and timely.
Skills : Planning Skills, Hiring Management.
Description :
Led, motivated, coached, trained, and assisted full time employees in day to day operations.
Micro managed problem account issues with staff for immediate resolution.
Set up payment arrangements, documented all contacts, responded to patient complaints, issued discounts, write offs, and adjustment.
Monitored department and individual productivity.
Assisted in new hire process.
Worked on auto dialer in a call center setting.
Relocated to New York References References are available on request.
Experience
10+ Years
Level
Senior
Education
BS
Appeals Representative Resume
Summary : Over 13 years of high volume appeals, claims processing, customer service, problem solving, and analytical skills. Possess strong organisational, communication and computer skills. Demonstrates ability to effectively plan, coordinate, and prioritise multiple projects simultaneously. Works well independently and with others.
Skills : Microsoft Office, Content Management.
Description :
Resolved appeals and grievances via telephone and written requests.
Ensured all responses are accurate, timely, address major issues and are user friendly and comprehensive to the customer.
Maintained all performance standards set for this position.
Researched inquiries utilizing available resources and online files, to include all internal reference materials, processes and procedures.
Ensured the contents of all written inquiry responses are in accordance with CMS regulations, while developing the ability to identify and research inquiries that require a higher level of expertise.
Adjusted claims according to Medicare Guidelines using MCS, MCSDT and CICS.
Assisted in the assessment of training needs.
Experience
10+ Years
Level
Senior
Education
Diploma
Appeals Representative Resume
Summary : Highly qualified Appeals Representative with experience in the industry. Enjoy creative problem solving and getting exposure on multiple projects, and I would excel in the collaborative environment on which your company prides itself.
Skills : Microsoft Word, Documentation Skills, Interpersonal Skills.
Description :
Transferred to customer service in 1999.
Handled phone calls and letters from clients regarding their coverage issues.
Transferred to the claims appeals department.
Handled written requests from Doctors and clients regarding denial of coverage issues.
Composed and mailed letters regarding these issues.
Spent several years in the fluid power industry doing inside sales, inventory, and payroll as well as accounts payable and receivable.
Referenced for these jobs can be furnished on request.
Experience
7-10 Years
Level
Management
Education
BS
Appeals Representative Resume
Headline : To obtain a challenging Appeals Representative position with diversity that will allow me to utilise my professionalism in secretarial, computer and customer service skills. Data Entry Customer Service Public Relations Troubleshooting Accounts Receivable Internet Research Microsoft Office/Excel/Work/PowerPoint/Outlook Records Maintenance.
Skills : Strong interpersonal, Assessment and engagement ,.
Description :
Reviewed medical records, documentation, asses medical polices, notes and all related information attached with appeals/claims.
Contacted providers to gather information and communicate disposition of case documents.
Interacted with triages clinical and non-clinical inquiries, including but not limited to finance and overpayment recovery units, grievances and appeals.
Prepared case files for member grievance committees/hearings, research and analyze reports and medical documentation.
Remain informed of laws and regulations that affect policies and procedures regarding appeals.
Provided direct information to the clinical specialist or medical director and legal counsel.
Responded to oral and written complaints sent to the Office of the Chairman, President or Vice President.
Experience
5-7 Years
Level
Executive
Education
Master Of Arts
Appeals Representative Resume
Summary : Dedicated, service-focused Appeals Representative professional seeking to transition into healthcare as a Medical Billing and Coder. Highly motivated to launch nursing career with license; future goals include education teaching Medical Billing and Coding. Reliable attention to detail worker with the ability to quickly learn new concepts and skills. Backed by solid work history, reputation as a learn player, leader, and passion for helping others.
Skills : Excel, Microsoft Word, Computer, Customer Service, Data Analysis.
Description :
Worked from home-contract labor Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
Utilized guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
Excluded conducting any utilization or medical management review activities which require the interpretation of clinical information.
Worked independently to research the Part B system to locate ICNs, provider numbers, and HIC numbers for determining the payee number and the claim status Research to identify Workers Comp, Liability, Working Age, Disability and ESRD.
Confirmed valid secondary records in HIMR Work independently to monitor all system activities initiated to maintain an awareness of the accurate and timely processing of each transaction by utilizing the aged system reports in MCS.
Performed follow-up procedures required to achieve a complete resolution to each aged activity.
Trained every year for HIPPA, Fraud & Abuse, Security and Compliance.
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