MARKET APPEALS SPECIALIST- CENTRAL APPEALS OFFICE

Responsibilities

• Complete all standard appeals timely and manage appeal inventory through ongoing tracking and monitoring.
• Act as a liaison with local facilities and payers to ensure timely appeal processing including appropriate follow-up with payers for facility reimbursement.
• Participate in local facility UM team meetings to support the standard appeal process.
• Provide feedback to providers and UM team on opportunities impacting facility recoveries (e.g., documentation).

Requirements

• Bachelor's degree required, Master's preferred
• RN License or Master's level clinician required, License preferred
• 3-5 years related experience required, 5-8 preferred
• Knowledge of utilization management operations, including experience with appeal letters and payer engagement.
• Proficient in Excel, Microsoft Office/Teams, Word, and database inventory management.
• Knowledge of payer requirements for reimbursement across all levels of care and behavioral health business office operations.
• Strong oral communication skills to represent patient progress and treatment in behavioral health.
• Understanding of medical necessity criteria application for all levels of care.
• Able to apply clinical acumen in behavioral health to written correspondence.