Physician Appeals Specialist

Full-time position, benefits eligible, 40 hours per week, Monday through Friday.

Responsibilities

• Escalated review of medical documentation at an advanced level from clinicians, qualified health professionals, and hospitals to validate medical necessity of the service rendered.
• Ensures correct code selection following Official Coding Guidelines and compliance with federal and insurance regulations and EMR and/or payer guidelines.
• Appeal advanced levels of medical appeals with insurance payers to recover denied payment while validating the integrity of the coded charges and billed claim.
• Reviews all clinician documentation to support assigned codes in the health information record so that all significant diagnoses and procedures may be captured for reimbursement and data purposes.
• Conduct independent research to promote knowledge of coding guidelines, regulatory policies, and trends.
• Provide education to Providers in denial practices and payer medical policies.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Practices ethical judgment in reviewing codes for proper insurance reimbursement.
• Maintains the confidentiality of patient records.
• Reports any perceived non-compliant practices to the coding leader or compliance officer.
• Recommend modifications to current policies and procedures as needed to coincide with government regulations.
• Responsible for processing medical necessity Claim Denials, when applicable.
• Responsible for appropriate appeal of denied claims utilizing professional coding oversight.
• Validates coding of physician billed services, including inpatient and outpatient procedures for all billable clinicians, ensuring claims are submitted to insurance payers in the most compliant, efficient, and expeditious manner possible.
• Accountable for accurate review and appeal of clinical and non-clinical information to create a comprehensive database for billing purposes, internal data management, and external reporting of data.

Requirements

• Coding Certification issued by one of the following certifying bodies: American Academy of Coders (AAPC) or American Health Information Management Association (AHIMA).
• Advanced training beyond High School in Medical Coding or related field or equivalent knowledge/experience.
• Typically requires 3 years of experience in professional coding including experiences in either hospital or professional revenue cycle processes and health information workflows.

Skills

• Advanced knowledge of ICD, CPT, and HCPCS coding guidelines.
• Advanced knowledge of medical terminology, anatomy, and physiology.
• Intermediate computer skills including the use of Microsoft Office products, electronic mail, and exposure or experience with electronic coding systems or applications.
• Advanced communication (oral and written) and interpersonal skills.
• Advanced organization, prioritization, and reading comprehension skills.
• Advanced analytical skills, with a high attention to detail.
• Ability to work independently and exercise independent judgment and decision making.
• Ability to meet deadlines while working in a fast-paced environment.
• Ability to take initiative and work collaboratively with others.

Physical Requirements and Working Conditions

• Exposed to a normal office environment.
• Must be able to sit for extended periods of time.
• Must be able to continuously concentrate.
• Position may be required to travel to other sites; therefore, may be exposed to road and weather hazards.
• Operates all equipment necessary to perform the job.

Pay

Pay range: $26.55 - $39.85 per hour.

Benefits

• Paid Time Off programs.
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability.
• Flexible Spending Accounts for eligible health care and dependent care expenses.
• Family benefits such as adoption assistance and paid parental leave.
• Defined contribution retirement plans with employer match and other financial wellness programs.
• Educational Assistance Program.
• Base compensation listed within the pay range based on factors such as qualifications, skills, relevant experience, and/or training.
• Premium pay such as shift, on-call, and more based on a teammate's job.
• Incentive pay for select positions.
• Opportunity for annual increases based on performance.

About the Organization

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia, and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience, and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics, and rehabilitation, as well as organ transplants, burn treatments, and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.