About the Role

Payer appeals is to provide concurrent review and appeal support services for services rendered and billed to insurance companies. Ideally, the candidate will have experience with utilization management, understand the state and federal regulations, have knowledge about the denials and appeals process and have experience with physician documentation and electronic health records. This is an excellent opportunity to be part of an organization where you can apply practical working knowledge to assist our patients to get the care they need.

Our team is comprised of passionate, forward-thinking professionals eager to take on the challenge of the mental health crisis and play a formative role in providing live-saving solutions. We are looking for a candidate who is inspired by our mission and excited by the opportunity to build a business that will impact millions of lives in a profound way. 

Responsibilities

• Assist with the denial management process and construction of appeal correspondence
• Determine if professionally recognized standards of quality care are met
• Recommend and request additional, more complete, medical record documentation
• Follow up on appeals with payers to ensure reimbursement is received for overturned denials
• Continually keep abreast of technology changes, regulatory issues, and medical practice through ongoing training and self-directed research
• Communicates both verbally and in writing with Providers and other departments, to resolve the provider reconsiderations
• Generates all correspondence (i.e. acknowledgment and resolution letters) to providers as required to comply with all relevant rules, regulations, and policies
• Requests, collects and logs all supporting documentation and related data including, but not limited to medical records, prior authorizations, member and/or practitioner/provider statements, claims, medical groups; maintains computer-based records and history of each case for liens
• Accurately maintains the reconsideration database to track and ensure compliance throughout the investigation process
• Ensures that letters used comply with required guidelines and timeframes
• Researches paid claims, answers inquiries, and coordinates with other departments
• Performs other duties of a similar nature and level as assigned, including assisting with overflow of provider appeals
• Additional functions as deemed appropriate

Requirements

• Able to work a hybrid schedule of 4 days/week in our Nashville office and located within 75 minutes' commuting distance of the office
• A minimum of two (2) years of provider appeals handling experience
• Highly organized and able to track workflows through various tools
• Proficiency with medical record technology required
• Experience working with health care benefits or Medicaid
• Principles and practices of the managed health care systems, and medical administration 
• Exercise exceptional judgment in decision-making, meet deadlines, and to work independently and with flexibility
• Problem solving skills
• Knowledge of CPT, ICD-9, and ICD-10
• Proficient in Microsoft Office tools (Word, Excel, PowerPoint)
• Understanding of the claim processing system

Benefits

Charlie Health is pleased to offer comprehensive benefits to all full-time, exempt employees. Read more about our benefits here.

Additional Information

Note: We are not currently considering applicants in CA, CO, NY, and WA for this position.#LI-HYBRID

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