Managed Care Appeals Specialist


HMH HOSPITALS CORPORATION Edison Requisition # 2021-90867 ShiftDay StatusFull Time with Benefits Weekend WorkNo Weekends Required HolidaysNo Holidays Required On CallNo On-Call Required Shift Hours8:30am - 5pm Address343 Thornall Street, Edison, 08837

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Overview

How have you impacted someone's life today? At Hackensack Meridian Health our teams are focused on changing the lives of our patients by providing the highest level of care each and every day. From our hospitals, rehab centers and occupational health teams to our long-term care centers and at-home care capabilities, our complete spectrum of services will allow you to apply your skills in multiple settings while building your career, all within New Jersey's premier healthcare system.

The Managed Care Appeals Specialist is responsible for the maximization of reimbursement by resolving managed care underpaid claims. The specialist serves as a liaison between the hospital and all managed care insurance companies for the purposes of obtaining clarification, correction of rates, and system issues to ensure the proper processing of claims in accordance with negotiated contracts. This position meets with insurance representatives, as needed to ensure proper reimbursement and for the submission of necessary documentation need for payment.

Responsibilities

A day in the life of Managed Care Appeals Specialist at Hackensack Meridian Health includes:

  • Must be able to understand managed care contracts, create project spreadsheets for submission to payers, write reconsideration appeals and send to MCOs, and be able to communicate both internally and externally for resolution of claim disputes.
  • Liaison to reduce underpayments by developing a working relationship with MCO provider advocates.  
  • Collaborate with all MCO payers to resolve payment errors and contractual disputes.
  • Resolve all claim issues that are affecting revenue due frommanaged care payers.
  • Submit monthly excel reports and written appeals letters to resolve external underpayments in a timely fashion.
  • Track MCO responses and send rebuttals as needed.
  • Meet with payers’ provider advocates to ensure prompt resolutions to payment
    issues.
  • Establish an effective follow-up protocol with both internal and externals partners.
  • Complete understanding of EPIC system is needed to identify payment discrepancies, monitor and track performance of recoveries, meet goals, audit claim payments, and identify other issues affecting revenue.
  • Gather information for audit review to ensure proper contract management allowances are posted, discover missing revenue potential
    for the organization, and makes corrections to accounts if needed.
  • Work closely with finance, legal, contracting, coding and billing departments on requirements and changes as they arise.
  • Other duties as assigned by Director of Operations or Manager of Epic Appeals.

Qualifications

Education, Knowledge, Skills and Abilities Required:

  • Minimum 3 years experience in health insurance, medical billing, or coding is required
  • High School diploma OR equivalent is required
  • Prior experience working with managed care claims and appeals processes for hospitals or special services is preferred
  • Must have fluency working with EPIC system
  • Understanding of EOBs, remittance advice, and vouchers
  • Ability to comprehend and apply contract language to maximize reimbursement for the organization
  • Full understanding of managed care contracts and payment methodologies
  • Ability to demonstrate skills with Microsoft Office, Patient Accounting systems, Patient Registration systems, and payer portals.
  • Strong communication skills and ability to de-escalate conversations to achieve organizational revenue goals
  • Ability to work independently, meet deadlines, troubleshoot, and present findings.
  • Must be detail-oriented with strong critical thinking and organization skills.

Education, Knowledge, Skills and Abilities Preferred:

  • Bachelor's Degree in a reated field
  • Epic Certification

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!

Our Network

Hackensack Meridian Health (HMH) is a Mandatory COVID-19 and Influenza Vaccination Facility

As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.