Government Audit & Appeals Specialist I (Remote)

What We Do

Adheres to Stanford Health Care’s organization competencies and Code of Conduct.
Denial Analysis: Conduct thorough analyses of denials, evaluating the appropriateness of medical services and procedures. Ensure accurate coding with ICD, HCPCS, CPT codes, as well as APC and DRG assignments, while identifying instances of overpayments and underpayments.
Appeal Letter Drafting: Independently compose professional and comprehensive appeal letters to payors after a detailed review of medical records. Ensure compliance with Medicare, Medicaid, third-party guidelines, Local Coverage Determinations (LCD), National Coverage Determinations (NCD), clinical documentation, coding guidelines, and payor policies to effectively challenge denials.
Appeal Strategies Development: Create comprehensive appeal strategies based on relevant guidelines and documentation to effectively address denials.
Submission of Appeals: Draft and submit detailed appeal letters along with supporting documentation, ensuring adherence to regulatory requirements and payor guidelines.
Appealability Scoring: Provide a thoughtful appealability score for each denial under review, assessing the likelihood of a successful appeal.
Proofreading and Editing: Review and edit appeals for clarity and accuracy prior to submission to ensure high-quality presentation.

What You Bring

Affinity for healthcare and a passion for helping others.
Strong analytical and problem-solving skills.
Excellent written and verbal communication skills.
Ability to work independently and as part of a team.
Proficiency in healthcare claims analysis, coding, and regulatory requirements.

Qualifications

• Associate’s degree in a work-related discipline/field from an accredited college or university (or equivalent combination of education/experience)
• Minimum three (3) years of progressively responsible, related work experience in healthcare revenue cycle management, with at least two (2) of those years being in a role which included claim-related appeal writing.
• Minimum two (2) years’ experience in medical coding.
• EPIC EHR and 3M Encoder experience.

Education

Required:
Associate’s degree in a work-related discipline/field from an accredited college or university (or equivalent combination of education/experience)
Preferred:
Bachelor’s degree in a work-related discipline/field from an accredited college or university

Experience

Required:
Minimum three (3) years of progressively responsible, related work experience in healthcare revenue cycle management, with at least two (2) of those years being in a role which included claim-related appeal writing.
Minimum two (2) years’ experience in medical coding.

Skills

• Ability to manage, organize, prioritize, multi-task, and adapt to changing priorities while meeting deadlines.
• Ability to communicate effectively in written and verbal formats including summarizing data and presenting results.
• Extensive writing capabilities and efficiencies.
• Ability to influence outcomes through convincing arguments supported by data.
• Ability to apply critical thinking skills to identify patterns and trends.
• Ability to mediate and solve complex work problems and issues.
• Ability to effectively facilitate work groups to successful outcomes.
• Knowledge of medical and insurance terminology, MS-DRG, APR-DRG, CPT, ICD coding structures, and billing forms (UB, 1500).
• Experience with coding, clinical validation, and medical necessity for inpatient stays.
• Knowledge of third-party payor rules and regulations.
• Knowledge of local, state, and federal healthcare regulations.
• Knowledge of detailed healthcare corporate compliance functions and audits to identify and eliminate waste, fraud and abuse, and inefficiencies in conformance with prescribed laws, regulations, and standards, reach independent decisions and logical conclusions, and prepare reports of findings and recommendations.
• Ability to model and demonstrate consistently high standards of professional ethics, integrity, and trust.
• Ability to maintain confidentiality of sensitive information.
• Ability to maintain competency and up-to-date knowledge of healthcare compliance, billing and coding requirements, practices, and trends.
• Proficiency in computer systems, specifically EPIC and 3M.
• Proficiency in computer software, including Microsoft Word, Excel, and Power Point.
• Ability to adapt to changing priorities and shifts in denials and appeals activity while maintaining high standards of accuracy and compliance.
• Demonstrated flexibility in responding to new challenges and evolving healthcare regulations.

Benefits

Stanford Health Care offers a comprehensive benefits package that includes:

• Health Insurance
• Retirement Savings Plan
• Flexible Spending Accounts
• Life and Disability Insurance
• Employee Assistance Program
• Telemedicine Services
• Wellness Programs

Pay

$45.94 - $59.73 per hour

Schedule

Full-time, Day Shift