At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews.
The Appeals Specialist I is responsible for performing triage, review, analysis, and resolution of facility-submitted appeals, involving non-clinical appeals, and clinical appeals where no new clinical information is received for review. The role focuses on payment, reimbursement, and administrative determinations. Ensuring appeals are processed accurately, thorough, timely and in compliance with client and organization requirements.
Responsibilities
This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of the department and MedReview in general.
Triage admin appeals to validate appropriateness for review and workflow to follow. Route appeals appropriately when new information is received that’d warrant a clinical review
Process non-clinical facility appeals including payment disputes, reimbursement amounts, contract interpretation, processing errors. Analyze payment history, contracts, in client(s) applications
Process clinical appeals when no new clinical information is submitted
Determine appeal decisions in accordance with existing policies from client and/or organization
Provide clear, thorough, and accurate appeal responses
Coordinate and communicate with Clinical Review teams when new clinical information is received or when escalation is required
Communicate with various stakeholders to bring forth emergent matters or trends
Qualifications
Associate degree (healthcare field preferred) or an equivalent combination of education, and relevant work experience
1 year experience working in healthcare claims, appeals, billing or revenue cycle
Experience in handling administrative review of clinical appeals
Strong professional judgement and escalation awareness with the ability to analyze case details to make timely and sound decisions
Ability to quickly learn and navigate new systems and platforms
Basic understanding of claims adjudication process and terms
Excellent written and verbal communication skills for effective interaction with diverse stakeholders
Ability to manage tasks, and prioritize work in an effective way
High attention to detail and document accuracy
Proficiency in MS Office applications (Outlook, Excel, Word)
Must be able to multitask, manage high volume case load, and work in a challenging environment to meet strict time sensitive deadlines
Ability to work independently
Must show patience and the ability to remain calm under pressure in an atmosphere of frequent interruptions
Remote Work Requirements
High speed internet (100 Mbps per person recommended) with secured WIFI.
A dedicated workspace with minimal interruptions to protect PHI and HIPAA information.
Must be able to sit and use a computer keyboard for extended periods of time.
Salary: $50,000
MedReview is a different type of payment integrity company. As a physician-led organization, our doctors review and document every claim we reassign, resulting in the highest savings per review and the lowest appeal overturn rate in the industry. Our advanced algorithms are enriched by machine learning and decades of clinical and claims data, enabling us to target claims with the highest potential for inaccuracy and abuse.
With a passion for ensuring claims fairly represent the care provided, MedReview offers pre- and post-pay billing audits with clinical reviews that save millions of dollars a year for our clients. Our full range of services include industry-leading solutions in payment integrity, utilization management and quality assurance.
