PathGroup

Compensation

Full Description

Job Summary:   The Appeals Specialist prepares and submits appeal packages, ensuring compliance with payer policies and regulatory guidelines. Responsibilities include reviewing documentation for accurate appeal language, monitoring appeal status, and following up on outstanding cases. The role requires expertise in medical claims processing and effective collaboration with internal and external stakeholders to maintain precise documentation.   JOB RESPONSIBILITIES:   * Prepare, document, and submit appeals for complex scenarios, ensuring appeals are well supported with clinical evidence, coding guidelines, and regulatory requirements. * Coordinate appeal responses with business partners. * Utilize applicable tools and resources to complete appeals by reviewing supporting documentation. * Proactively address discrepancies between payer policies, regulatory standards, and internal processes to prevent future denials. * Other duties as assigned. Qualifications EDUCATION & LICENSURE:   * High school diploma or equivalent   REQUIREMENTS:   * 3+ years of healthcare revenue cycle experience with primary emphasis on denial research and appeal processing. * Experience with laboratory billing preferred. * Familiarity with Xifin billing system a plus.   ABILITIES: * Solid understanding of healthcare RCM processes, including ICD-10 and cpt coding. * Ability to interpret payer policy and CMS guidelines as it relates to appeal processes. * Ability to meet deadlines and work independently. * Excellent written and verbal communication skills. * Proficiency with Microsoft applications and ability to work across multiple software systems. * Strong attention to detail, organizational and time management skills with the ability to * interpret, research, and identify core issues. * Strong customer focus, analytical and decision-making skills.