Healthcare Appeals Specialist in Portland, Oregon - #73412 | VanderHouwen

Description

Job Id: 73412

Healthcare Appeals Specialist
Our client is seeking a Healthcare Appeals Specialist to join their team. In this role, you will review and resolve provider billing disputes and appeals, acting as a knowledgeable and courteous point of contact for providers, members, and other stakeholders. You will work with clinical and coding colleagues to reach timely, well-documented decisions that comply with contractual and regulatory requirements.

This role is fully remote. Applicants must reside in Oregon, Washington, Idaho, Utah, or North Dakota.

Healthcare Appeals Specialist Responsibilities

• Analyze provider billing disputes and appeals by reviewing claim coding, claim processing history, medical and reimbursement policies, benefit contracts, and applicable regulations.
• Validate incoming appeals for timeliness, member benefits, employer group, and provider contract provisions, and record all information accurately in the appropriate systems.
• Make non-clinical appeal determinations within department guidelines, and route cases to licensed health professionals when clinical review is required.
• Collaborate with coding specialists, appeal nurses, and physician reviewers to reach timely decisions, and present complex cases to appeal panels when needed.
• Communicate decisions clearly to members, providers, and their representatives, and help them understand the appeal process and the supporting information required.
• Coordinate external review cases by gathering documentation, preparing letters and case files, serving as the liaison between the provider and the review organization, and implementing the final decisions.
• Manage an assigned caseload while meeting strict timeliness, productivity, and quality standards.
• Track appeals and maintain files, and assist with reporting on case volumes, decision trends, timeline compliance, and process improvement ideas.
• Serve as a subject matter resource on appeal policies, procedures, and appeal rights, including serving as an expert witness when called upon.

Healthcare Appeals Specialist Qualifications

• High school diploma or GED with a minimum of 4 years of experience in customer service, claims, or clinical services within a health plan environment, or an equivalent combination of education and experience.
• Working knowledge of medical terminology, anatomy, and coding (CPT, diagnosis codes, and HCPCS), along with an understanding of claims processing and clinical services operations.
• Coding certification preferred.
• Strong analytical and problem-solving skills, with the initiative to research issues, develop solutions, and carry them through.
• Excellent verbal and written communication skills, with the ability to explain complex medical and reimbursement information diplomatically and persuasively.
• Professional, discreet, and empathetic approach to all internal and external contacts, with a commitment to confidentiality.
• Ability to prioritize competing work, shift between tasks as business needs change, and consistently meet tight deadlines without sacrificing quality.
• Intermediate proficiency with Microsoft Word, Excel, and Outlook, and the ability to learn proprietary claims systems.

Compensation: $30-$33/hr. (DOE)

VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
As an eligible contract employee with VanderHouwen, you’ll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

Meet VanderHouwen
What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we’re in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies’ staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.

VanderHouwen is an award-winning, Women & Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!

VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.

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