Medical Appeals Specialist

OrthoMed Anesthesia is seeking a highly skilled and experienced Medical Revenue Cycle Management Appeals Specialist to join our team. As a leading healthcare organization, specializing in anesthesia, we are committed to ensuring accurate reimbursement and maximizing revenue while upholding compliance with industry regulations. This position is critical in managing appeals and arbitration processes to resolve payment disputes and optimize revenue cycle outcomes.

Position: Medical Revenue Cycle Management Appeals Specialist

Location: Addison, TX

Employment Type: Full-time

Responsibilities:

• Review and analyze denied claims, payment discrepancies, and reimbursement issues to identify the root causes.
• Initiate and manage the appeals and arbitration process for denied or underpaid claims, ensuring timely and accurate submissions.
• Prepare compelling appeal letters, supporting documentation, and necessary forms to present a strong case for claim reconsideration.
• Collaborate with internal departments, healthcare providers, and payers to gather additional information and supporting documentation for appeals.
• Stay up-to-date with payer policies, regulations, and industry trends related to claim appeals and arbitration.
• Maintain a comprehensive understanding of coding guidelines, medical necessity, and reimbursement methodologies to strengthen appeal arguments.
• Track and document all appeal activities, ensuring accurate and timely follow-up.
• Coordinate with external legal counsel and compliance teams, when necessary, to handle escalated disputes and arbitration cases.
• Analyze denial and appeal trends, identify patterns, and provide recommendations for process improvements to minimize future denials.
• Participate in revenue cycle meetings, providing updates and insights on appeal status, recovery trends, and potential revenue impact.

Qualifications:

• High school diploma or equivalent; associate or bachelor's degree in healthcare administration or related field preferred.
• Proven experience as a Medical Revenue Cycle Management Appeals Specialist or in a similar role within a healthcare setting.
• In-depth knowledge of healthcare revenue cycle processes, claim adjudication, and reimbursement methodologies.
• Familiarity with insurance denials, appeals, and arbitration processes, including knowledge of payer-specific appeal requirements and guidelines.
• Strong understanding of medical coding (CPT, HCPCS, ICD-10) and medical terminology.
• Excellent analytical and problem-solving skills, with attention to detail and ability to evaluate complex claim scenarios.
• Effective written and verbal communication skills to compose persuasive appeal letters and interact with internal and external stakeholders.
• Proficient in using computer systems, including MS Office applications and claims management software.
• Ability to work independently and as part of a team, managing multiple priorities and meeting deadlines in a fast-paced environment.
• Strong organizational and time management skills, with a proactive approach to resolving issues and achieving optimal outcomes.

Join our dedicated team and contribute to the success of our revenue cycle management processes by effectively managing appeals and overturning denials. We offer a competitive salary, comprehensive benefits package, and opportunities for professional growth and development.

We appreciate your interest in joining our organization, and we will contact only those candidates whose qualifications closely match our requirements.

Please note that all applicants will be treated with confidentiality and that only selected candidates will be contacted for an interview.