The Appeal Specialist is responsible for developing persuasive letters of appeal to third-party payers to allow reimbursement at the highest level for patients and the organization. Key elements include effective education of payers on company products and the ability to apply a strong knowledge of insurance processes to navigate the appeal process across numerous health insurance companies (payers). This position will report to the Manager, Payer Operations on the Payer Operations team. The role is full time, exempt and will work remotely.
Description
Essential Duties and Responsibilities
The essential functions include, but are not limited to the following:
Draft persuasive letters of appeal to third-party payers to ensure maximum reimbursement potential utilizing patient clinical documentation
Ability to confidently educate health plan decision makers that include Medical Directors, Administrative Law Judges, health plan legal representatives regarding operation and use, features and benefits of Company products
Review clinical documentation and develop appeal strategies based on payer, strength of case and potential for approval
Provide advocacy and support to patients who are denied insurance coverage for products
Ability to engage patients when needed to assist in the appeal process
Identify payer trends and establish specific payer strategies to obtain coverage
Maintain a high level of accuracy while meeting productivity and quality requirements
Work with other departments to ensure accurate processing of patient orders and payer approvals and denials
Identify trends for process improvement and communicate to leadership
Assist in the development of internal processes and best practices for the payer operations department
Benefit and authorization process investigation
Follow all compliance and HIPAA requirements
Other duties as assigned
Minimum Qualifications
Education, Experience and Training
Bachelor’s degree or equivalent work experience
Previous experience in the medical device industry, payer appeals, Administrative Law Judge hearings, clinical record review or related field
Knowledge, Skills and Abilities
Excellent written and verbal communication skills
Excellent problem solving and analytical skills
Knowledge of regulatory guidelines for appeals and denials
Ability to produce grammatically accurate appeal and patient correspondence
High attention to detail
Ability to work under pressure to deliver accurate, and timely results
Proven ability to work independently, multitask, prioritize and meet required deadlines
Ability to be persuasive and credible with payers
Confidently speak about the operation and use of company products
Working knowledge and expertise of insurance processes
Technology savvy and able to navigate payer portal systems
Ability to work independently and in collaboration with a team
Able to provide clear and concise communication to payers, field reps, clinicians, peers and management via phone, email, video conference and/or in person
Core Competencies
Change Agent
Influencing
Communication
Process Management
Priority Setting
Peer Relationships
Critical thinking
Time Management
Drive for Results
Tools and Technology
Google Suite, Adobe, Salesforce CRM
Physical Functions and Work Environment
The physical functions described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.
While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers; handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus. The noise level in the work environment is usually low to moderate.
Note
This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any Koya manager authorized to provide instruction or assign work. Duties, responsibilities, and activities may change at any time with or without notice. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.