Insurance Appeals Rep
Summary
Insurance Appeals Representatives handle high-dollar or complex claim denials for hospital clients, reviewing clinical documentation and payer guidelines to draft effective appeals. They work to overturn denials and improve cash collections, with a daily quota of at least 10 appeals, acting as subject matter experts for their teams.
JOB SUMMARY
Under the supervision of the Insurance Supervisor, the Insurance Appeals Representative will work high dollar or complex denials for hospital insurance claims. The Appeals Representative will be responsible for reviewing basic clinical documentation and relevant payer guidelines to draft timely and effective appeals. They will be measured on appeals success and denials overturn rate, working to improve cash collections on behalf of their client(s). The Appeals Representative may directly write appeals or act as a consultant for other Insurance Reps, assisting them with referencing clinical or payer guidelines. They may be expected to share payer updates with Insurance teams or provide occasional information sessions to department trainer or representatives. They will prioritize work based on feedback from their leadership in order to best impact performance metrics.
ESSENTIAL FUNCTIONS
- Demonstrate extensive knowledge of insurance follow-up and denials.
- Act as the subject matter expert for appeals on their team.
- Triage and determine denial reasons from remittance advice, explanation of benefits, payer portals, or other avenues of information.
- Research pertinent payer medical policy bulletins and billing guidelines, creating a repository of reference materials for themselves and other team members.
- Prioritize work effort by viability and amount of payment to maximize cash.
- Track payer issues and escalations to provide relevant trending information to leadership.
- Follow appeals to resolution to assess effectiveness.
- Create job aids and share information on appeals language as needed.
- Practice compliant billing and follow-up strategies for all government and managed care payers.
- Meet minimum of 10 appeals per day, as well as any follow-up needed on existing appeals.
- Aggressively seek to resolve unpaid balances.
- Document all efforts accurately and thoroughly.
- Follow all workflow protocols.
- Work other insurance inventory as assigned or as volume demands.