Appeals Analyst Resume Samples
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Appeals Analyst Resume Samples
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AR
A Renner
Amelia
Renner
710 Lindgren Square
New York
NY
+1 (555) 267 3350
710 Lindgren Square
New York
NY
Phone
p
+1 (555) 267 3350
Experience
Experience
Philadelphia, PA
Appeals Analyst
Philadelphia, PA
Koch Group
Philadelphia, PA
Appeals Analyst
- Capturing and tracking issues
- CAP remediation planning and monitoring
- Communicating initiatives and their status
- Sharing process improvements
- Collaborating on compliance related issues
- Demonstrating trends
- Responding to issues
San Francisco, CA
Denials / Appeals Analyst
San Francisco, CA
Dibbert, Kris and Toy
San Francisco, CA
Denials / Appeals Analyst
- Performs additional duties as directed by the Denials Resolution Senior/Supervisor or the A/R Manager
- Computer literate, working knowledge of Excel helpful
- Monitor and review all payment denials as assigned in Enterprise Task Manager and process these claims in the time frame assigned within the system
- Consistently meet established completion times for projects and assignments
- Review carrier manuals and websites and informs management of any new procedures implemented by the carrier that are impacting our claims
- Contacts carriers to inquire on claims that have been denied and appealed
- General knowledge of ICD and CPT coding
present
Chicago, IL
Senior Appeals Analyst
Chicago, IL
Koelpin and Sons
present
Chicago, IL
Senior Appeals Analyst
present
- Review inquiries to determine if they meet definition of appeal/grievance
- Request and review all related relevant documentation and assemble case file
- Coordinate resolution results and relay investigative results with all involved parties
- Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends
- May support the Quality Assurance, Appeal and other quality committees
- Other duties as assigned or requested
- Supporting regulatory reporting updates and/or concerns
Education
Education
Bachelor’s Degree in Appropriate Knowledge
Bachelor’s Degree in Appropriate Knowledge
Ohio University
Bachelor’s Degree in Appropriate Knowledge
Skills
Skills
- Ability to use a personal computer and applicable software and systems
- Ability to analyze and resolve problems with minimal supervision
- Strong verbal and written communication skills
- Ability to multitask
- Excellent organizational skills
- Proficiency with computer platforms and applictaions
- Solid judgment skills
- Knowledge of contracts, enrollment, billing and claims coding/processing
- Knowledge Managed Care principles
- Polished and professional demeanor
7 Appeals Analyst resume templates
Read our complete resume writing guides
1
Appeals Analyst Resume Examples & Samples
- Proficiency with computer platforms and applictaions
- Solid judgment skills
- Knowledge of contracts, enrollment, billing and claims coding/processing
- Knowledge Managed Care principles
- Ability to analyze and resolve problems with minimal supervision
- Ability to use a personal computer and applicable software and systems
2
Grievance / Appeals Analyst Resume Examples & Samples
- HS diploma or equivalent
- 1-3 years of Grievance & Appeals analyst experience and 3-5 years’ experience working in grievances and appeals, claims, or customer service
- Facets experience required
- WMDS and WGS experience preferred
- Excellent written communication skills required
- Previous Grievance/Appeals experience preferred
3
Grievance & Appeals Analyst Resume Examples & Samples
- Associates Degree (AA/AS) and/or 2 to 3 years of administrative/secretarial experience with in the Health Care industry, required
- H/S Diploma or equivalent
- Intermediate computer skills (MS Word, Excel)
- Grievance and Appeals Experience
- Strong Organizational skills
- 40 to 45 words a minute, required
4
Appeals Analyst Resume Examples & Samples
- Stays current with press releases, emails, and other forms of communications relaying initiatives, contracting issues, as well as Plan wide concerns
- Demonstrates high degree of appropriate knowledge of all areas of the plan
- Identify and create action plans to educate internal departments on benefit misinterpretation and/or claim payment system errors
- Answer member/provider questions via incoming telephone calls in a professional quality driven manner
- Investigate member and provider appeals and grievances and NCDOI, Congressional and/or Department of Justice complaints for all lines of business, excluding FEP, by reviewing applicable resources (i.e. CMP, CMS guidelines, CPT coding guidelines, Reconsideration/Appeal Manual, contract provisions, legislation, Client management, and/or NCQA requirements
- Identify, collect, and analyze appropriate documentation from multiple internal systems including claims, customer contract management, benefit booklets, UM systems, coding claim edits, etc. and external sources including pharmaceutical companies, attorneys, providers, Medicare, PBMs, etc
- Coordinate and draft responses to NCDOI, Congressional and/or DOJ complaints with all Enterprise Departments to ensure timely and accurate resolution
- Consult and confer with medical directors and other clinical staff to ensure the appropriate decision has been made and the approved outcomes are implemented
- Review, analyze and make determinations on provider requests for increased payments related to coding and/or bundling issues
- Communicate findings of analysis and documentation to appropriate committee, benefit administrators and Client leadership, as necessary
- Initiate claim adjustments on individual cases when necessary and follow and track until completion
- Provide written documentation of case determinations to appellants and/or all involved parties (including but not limited to physicians, attorneys, senators/legislators, employer groups, etc.) in a timely manner as required by regulatory mandates and legislation
- Identify trends and high-risk issues to mitigate risk of potential legal actions and/or NCOI focused audits and penalties. Communicate findings to the Legal department, Corporate Communications, Special Investigations, and Healthcare Senior Management. Make recommendations to address future exposure
- Audit appeal and grievance files as required by Federal and/or State regulatory agencies and provide feedback, education and training to individual employees to ensure compliance with mandates
- Audit and oversight of entities where delegation of member and provider appeals exists
- Identify and take corrective action on appeals or grievances that result from noncompliance of contract provisions, appeal or grievance guidelines, provider contract violations and/or medical policies
5
Grievance / Appeals Analyst Resume Examples & Samples
- 3 to 5 years experience working in grievances and appeals, claims, or customer service, familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology
- Or any combination of education and/or experience which would provide an equivalent background
- Medicare knowledge required
- Positions must be located in the Mason, OH or Wallingford, CT office. No work at home option available
6
Grievance / Appeals Analyst Resume Examples & Samples
- Requires a High school diploma or GED
- At least 3 to 5 years experience working in grievances and appeals, claims, or customer service required
- Familiarity with dental coding and dental terminology preferred
- Demonstrated business writing proficiency required
- Understanding of provider networks, the medical management process, claims process, the company's internal business processes preferred
7
Appeals Analyst Resume Examples & Samples
- Be the voice and primary contact of Appeals and Grievances by
- Actively participating in meetings
- Responding to issues
- Communicating initiatives and their status
- Sharing process improvements
- Collaborating on compliance related issues
- CAP remediation planning and monitoring
- Driving process improvements
- Demonstrating trends
- Remediation planning on receipt drivers
- Monthly status of improvements
- Structure and discipline in our reporting and presentations
- Capturing and tracking issues
- Supporting audits
- Supporting regulatory reporting updates and/or concerns
- Update/correct and ensure compliance of our standard operating procedures
- Associate's Degree (or higher) or High School Diploma/GED with 5+ years of experience in healthcare operations (claims, call center, and/or appeals and grievances)
- 5+ years of experience in healthcare operations (claims, call center, and/or appeals and grievances)
- Intermediate proficiency with Microsoft PowerPoint (create and edit presentations), Excel (formulas, pivot tables), and Word (documents, editing)
- Experience with one of the following systems: Careone, CSP Facets, ICUE or ETS
- Project Management/Account Management experience
- Written and Verbal
- Ability to give presentations
8
Grievance / Appeals Analyst Resume Examples & Samples
- Requires a High School diploma/GED
- 1-3 years experience in health insurance business including customer service experience
- Good verbal and written communication, organizational and interpersonal skills
- Bilingual in English-Spanish preferred
- Managed Care experience required
- PC proficiency preferred
9
Denials / Appeals Analyst Resume Examples & Samples
- Monitor and review all payment denials as assigned in Enterprise Task Manager and process these claims in the time frame assigned within the system
- Utilize the telephone and various carrier websites as research tools to expedite resolution for issues
- Assembles and forwards documentation to appeal disputed claims
- Assist with research and development of appropriate denial procedures
- Contacts carriers to inquire on claims that have been denied and appealed
- Assembles and forwards appropriate documentation to the Senior Analyst for provider related issues
- Review carrier manuals and websites and informs management of any new procedures implemented by the carrier that are impacting our claims
- Reports any consistent errors found during claims review that may affect claims from being processed correctly
- Consistently meet established completion times for projects and assignments
- Consistently meet and maintain the QA (95% or better) and designated production standards per sub-team
- Performs additional duties as directed by the Denials Resolution Senior/Supervisor or the A/R Manager
- Job Requirements
- Thorough knowledge of physician billing policies and procedures
- Thorough knowledge of healthcare reimbursement guidelines
- Computer literate, working knowledge of Excel helpful
- Good organizational and analytical skill
- One to three years’ experience in physician medical billing with emphasis on research and claim denials
- General knowledge of ICD and CPT coding
10
Core Appeals Analyst Resume Examples & Samples
- 1) Writing, reviewing, managing and administering grants under FEMA's Public Assistance Program to assist in the recovery of affected areas following a declared Stafford Act disaster
- 2) Resolving issues related to appeals and audits under FEMA’s Public Assistance Program through research, analyses, and development of responses to grant related matters in dispute
- 1) Writing, reviewing, and managing and guiding the research, analyses, and development of responses to appeals and audits under FEMA's Public Assistance Program
- 2) Demonstrated experience advising leadership and other audiences on the strategy and approach to resolving PA program matters in dispute
- 3) Writing, reviewing, and administering grants under FEMA's Public Assistance Program in addition to managing Public Assistance program delivery to assist in the recovery of affected areas following a declared Stafford Act disaster
11
Appeals Analyst Resume Examples & Samples
- 3-5 years of experience in appeals and grievances
- A High School Diploma or GED
- Experience in Customer Service or a related field
- Knowledge of multiple processing systems and workflows
- Knowledge of claims processing methodologies
- Ability to interpret all government regulations
12
Senior Appeals Analyst Resume Examples & Samples
- Goal-oriented – holds him/herself accountable to achieving shared and personal goals
- PC skills - demonstrates high proficiency in Microsoft Office applications and others as required
- Mathematical skills - able to perform advanced mathematical calculations and balance and reconcile figures
- Two years of related experience
13
Senior Appeals Analyst Resume Examples & Samples
- Review inquiries to determine if they meet definition of appeal/grievance
- Request and review all related relevant documentation and assemble case file
- Coordinate resolution results and relay investigative results with all involved parties
- Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends
- May support the Quality Assurance, Appeal and other quality committees
- 5+ years of relevant, progressive experience in the area of specialization
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14
Grievance / Appeals Analyst Ld-eagan MN Resume Examples & Samples
- 3 to 5 years of Grievance & Appeals Senior analyst experience preferred
- Excellent understanding of dental coding and medical terminology, demonstrated high quality business writing proficiency, in depth knowledge and understanding of provider networks, the dental or medical medical management process, claims process, WellPoint internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background
- Associate's or BA/BS degree preferred
- Ability to travel up to 25% required
15
Grievance / Appeals Analyst Resume Examples & Samples
- Medicare/Medicaid and CMS regulation experience preferred
- Medicare Supplemental experience preferred
- Have strong ability to handle escalated presidential issues
- Writing Sample maybe required
16
Appeals Analyst Resume Examples & Samples
- Implements process for identifying under-allowed claims using software and other available tools
- Reviews and analyzes EOBs for identified under-allowed claims
- Verifies applicable contract by, as dictated by operational procedures: reviewing EOB messages, reviewing patient ID card, verifying member information for managed care plans
- Uses feedback and experience to refine communication skills and tools for use in preparing written and telephone appeals
- Batches appeals by payer or network, by CPT/HCPCS code combination, by error type, or by provider
- Compiles and submits appeals, and monitors for proper reimbursement
- Uses software to track appeals and recoveries
- Establishes and cultivates helpful and effective contacts in payer or network offices
- Establishes follow-up protocol with payers and networks
- Prepares monthly performance statistics regarding appeals and recoveries
- Monitors and tracks contractual, billing, registration, and posting errors, and provides continuous feedback to Appeals Manager
- Participates in meetings to discuss ongoing trends and issues regarding the administration of managed care contracts
- Maintains the strict confidentiality required for medical records and other data
- Participates in professional development efforts to ensure currency in managed care reimbursement trends
- Minimum of two years’ experience working with managed care claims and appeals for health care professional services (physicians and other health care professionals)
- Experience in a production environment desirable but comfort in such an environment is essential
- Advanced knowledge and PC skills, with proficiency in utilizing Microsoft office products (Word, Excel, Outlook, PowerPoint, etc.)
- Knowledge of the health care professional services billing (physicians and related health care professionals) and reimbursement environment
- Knowledge of major types of practice management system (PMS) and EOB imaging systems, with experience working with at least one industry leading PMS highly desirable
- Knowledge of networks, IPAs, MSOs, HMOs, PCP and contract affiliations
- Knowledge of managed care contracts and compliance
- Demonstrated skill in gathering and reporting claims information
- Demonstrated skill in written and oral communication with colleagues, supervisors, and payer/network personnel
- Demonstrated skill working in a team-oriented structure to achieve goals
- Demonstrated skill in problem solving and research
- Ability to work effectively with other departments and management
- Ability to identify, analyze and solve problems and to recognize patterns in data
- Ability to learn, understand and use the software application
17
Grievance / Appeals Analyst Resume Examples & Samples
- Microsoft Office Experience preferred
- At least 3 years of customer service experience is preferred
- Familiarity with medical terminology preferred
- Experience in a production environment required
18
Grievance / Appeals Analyst Resume Examples & Samples
- 3 to 5 years experience working in grievances and appeals, claims, or customer service,
- Demonstrated business writing proficiency,
- Understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology
- WGS experience required
- STAR experience preferred
- Previous claims procedure or adjustment experience required
19
Grievance / Appeals Analyst Resume Examples & Samples
- Requires a High School diploma/GED,
- 1-3 years experience in health insurance business including customer service experience,
- Good verbal and written communication, organization and interpersonal skills
20
Grievance / Appeals Analyst, / II Resume Examples & Samples
- 3 to 5 years' experience working in grievances and appeals, claims, or customer service,
- Familiarity with medical coding and medical terminology,
- Understanding of provider networks, the medical management process, claims process, Anthem internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background
- Excel, CS/90, some knowledge of ECC, good understanding of Grievance & Appeals required
- WGS, WMDS, On Demand and WCF experience preferred
