RCM Specialist

RCM Specialist - Appeals

Department: RCM

Reports to: RCM Manager

Pay Group: Hourly

Job Summary:

As a key member of the Gravity RCM Team, the RCM Specialist II - Appeals is responsible for processing appeals through the ability to analyze, research, and successfully appeal third party claims within established timelines. This position will develop payer and provider relationships to effectively appeal and obtain full contractual or out-of-network payment on claims. The RCM Specialist II- Appeals, in conjunction with a multidisciplinary team, utilizes clinical expertise, insurance knowledge, business know-how, and high-level communication to analyze accounts/claims, medical records and invoices to assist in the resolution for retrospective approval for fully or partially denied services. This person will serve as a strong and knowledgeable liaison between insurance payers while maintaining cross functional communication between all teams.

Responsibilities and Duties:

• Logs, tracks, and processes appeals and grievances.
• Conduct research.
• Analyzes and articulates trends specific to denials, root cause, and A/R impact.
• Contacts payer and makes inquiries on account/claim status. Escalates problem claims and initiates the appeal process.
• Documents billing activity on the patient claim according to departmental guidelines.
• Ensures compliance with all applicable billing regulations and reports any suspected compliance issues to departmental leaders.
• Properly documents accounts/claims clearly with indicators and activities so that tracking and trending can be prepared for further analysis.
• Ensures all work is compliant with privacy, HIPAA, and regulatory requirements.
• Identify trends with claim denials and provide communication to all necessary parties.
• Responsible for accurate and timely processing of authorizations for approval services.
• Communicate with insurance companies about coding errors, disputes, appeals follow-up. Discuss what is needed to finalize.
• Review accounts flagged for prior authorization request needs and work any prior authorization requests, reviewing payer portals and taking corrective action.
• Maintain accurate records/communication of project work, documentation and keep SOP’s and call logs updated.
• Reports to management any policy discrepancies, deficits, or best practice deviations to ensure timely resolution to mitigate risk.
• Reports to management any reimbursement/ denial trends due to payor policy changes or application of current policies impacting claims.
• Add additional information to appeal/reconsideration letters.
• Ensure Submitted Claims are processing and the TELCOR view is up to date.
• Participates in general or special assignments and attends all required meetings/training.
• Assist with appeals configurations.
• Miscellaneous responsibilities and projects as assigned.

Required Skills and Abilities:

• Must possess excellent verbal and written communication skills, interpersonal and customer service skills.
• Strong attention to detail identifying billing issues and resolving errors.
• Must be able to read and interpret explanation of benefits (EOBs).
• Understanding of medical claims billing, coding and terminology.
• Ability to utilize experience, tribal and acquired knowledge and other sources to effectively develop and deploy claims appeals strategies.
• Ability to communicate and resolve complex issues with external customers and stakeholders.
• Excellent project management skills
• Proficient in Microsoft Excel

Education and Experience:

• Minimum 5-years of experience working in revenue cycle with a focus on claims appeals.
• Customer and/or payor facing experience.
• Experience navigating and effectively using online health plan portals.
• CRCR, CPC, CPPM or other revenue cycle certification preferred.
• Bachelor’s degree preferred.

Physical Requirements:

• Prolonged periods of sitting at a desk and working and typing on a computer.
• Prolonged periods of time on phone calls

Gravity Diagnostics is an Equal Opportunity Employer. All persons shall have the opportunity to be considered for employment without regard to their race, color, religion, national origin, ancestry, alienage or citizenship status, age, sex, gender, gender identity, gender expression, sexual orientation, marital status, disability, military service and veteran status, pregnancy, childbirth, and related medical conditions, or any other characteristic protected by applicable federal, state or local laws.

Gravity Diagnostics will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business.

Job Type: Full-time

Pay: From $18.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• Office

Work Location: In person

Salary : $18 - $0