Claims & Appeals Specialist II

General Purpose of Job

The Claims and Appeals Specialist II is a certified medical coder that performs audits for correct coding and claims payments and oversees the claims appeal process for provider and member appeals. This position also investigates Coordination of Benefit (COB) claims. The Claims and Appeals Specialist II reports to the Director of Claims Oversight.

Essential Duties and Responsibilities

• Maintains the utmost level of confidentiality at all times.
• Adheres to hospital and DHP policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Reviews claims appeal and makes recommendations regarding reprocessing/denial of payment.
• Researches provider’s claims questions.
• Works closely with Provider Relations Representatives to assist with provider claim issues.
• Provides insight to potential claims payment issues.
• Notifies Compliance Officer for DHP of potential fraud and abuse.
• Responds to providers regarding claims-related issues.
• Coordinates re-consideration of claims with DHP’s Third Party Claims Administrator.
• Coordinates coordination of benefit activities.
• Active member of bi-weekly claims meetings between DHP and DHP’s Third Party Claims Administrator.

Education and/or Experience

• High school diploma or general education degree (GED).
• Associate’s degree (A. A.) or equivalent from two-year college or technical school.
• Three to five years related experience and/or training.
• Equivalent combination of education and experience.
• Three to five years’ experience of coding in an acute care hospital setting preferred.