Physician Appeals Specialist

About the Role

The Physician Appeals Specialist is responsible for the validation of coding of physician billed services, including inpatient and outpatient procedures for all billable clinicians, ensuring that claims are submitted to insurance payers in the most compliant, efficient and expeditious manner possible. This position is accountable for accurate review and appeal of clinical and non-clinical information to create a comprehensive database of information for billing purposes, internal data management, and external reporting of data. This position has a direct financial impact.

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.

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, including 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.

Benefits

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development, and more – so you can live fully at and away from work.

• 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.

Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.).

Pay

Pay Range: $26.55 - $39.85 per hour.

Schedule

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