Appeals Resolution Specialist

Company Description:

Duties and Responsibilities / Essential Functions:

• Review and manage assigned deferrals, denials, and appeals to determine the appropriate course of action and ensure timely resolution.
• Analyze payer correspondence, denial reasons, authorization requirements, medical documentation, and account history to identify the underlying cause of the payer decision.
• Research payer policies, coverage criteria, contractual requirements, and applicable guidelines to determine appeal opportunities and resolution strategies.
• Prepare clear, accurate, and persuasive appeal submissions supported by appropriate documentation and payer requirements.
• Coordinate with internal departments to obtain missing or additional documentation necessary to support an appeal or resolve a deferral.
• Communicate directly with payers, healthcare providers, and internal stakeholders to clarify requirements, address outstanding issues, and facilitate resolution.
• Monitor appeal deadlines and payer response timeframes to ensure cases are worked within established requirements.
• Perform appropriate follow-up throughout the appeal process and escalate complex or high-risk cases when necessary.
• Maintain complete and accurate documentation of appeal activity, payer communication, decisions, and resolution outcomes within applicable systems.