Medical Appeals Consultant

We are seeking a detail-oriented and knowledgeable individual to join our team as a Consultant – Appeals. In this role, you will be responsible for handling disputes in the Independent Dispute Resolution process between healthcare providers and insurance companies. This role requires a deep understanding of healthcare services and items, and strong critical thinking and writing skills.

Position: Arbitration Consultant- Medical Appeals

Pay rate: $25/hr

Fully Remote

Key Responsibilities:

• Render payment determinations on disputes between providers and health plans.
• Review submissions from both parties and ensure all documentation is complete and accurate.
• Conduct thorough analysis of the dispute, considering the qualifying payment amount (QPA), other factors relating to factors as identified in regulations and guidance, and other relevant additional documentation submitted by the parties.
• Render final and binding payment determinations decisions in a timely and impartial manner based on the documentation provided relating to the QPA and decision-making factors.
• Interpret laws and procedure to settle disputes.
• Request additional information from parties where necessary.
• Handle disputes and ensure all steps are completed to finalize disputes.
• Utilize case processing systems to document all steps in the process and the findings.
• Research and resolve dispute questions or concerns.
• Maintain up-to-date knowledge of relevant regulations.
• Meet Productivity and Quality Standards.

Essential Duties and Responsibilities:

• Serve as a subject matter expert for the most complex Appeals and Hearings cases.
• Evaluate data associated with complex customer issues to determine compliance or make exceptions to applicable regulations and policies; may require contacting the customer to obtain additional information or clarify actions pertinent to the case.
• Research laws and regulations and apply rules to case-specific situations.
• Provide complaint resolution to customers verbally or in writing, utilizing discretion.
• May attend hearings and/or management meetings to discuss cases.

Minimum Requirements:

Qualifications: Education:

• Bachelor's degree required with at least five years of experience in payment determinations on disputes between providers and health plans, handling disputes in the Independent Dispute Resolution process between healthcare providers and insurance companies. Certifications in lieu of education will be considered.
• Law degree, paralegal, RN strongly recommended but not required.

Experience:

• Experience in healthcare law, arbitration, mediation, dispute resolution, or claims adjudication in healthcare.
• Strong analytical and critical thinking skills.
• Excellent written and verbal communication abilities.
• Ability to handle sensitive information with integrity and confidentiality.
• Healthcare Coding experience preferred.

Skills:

• Persuasive communication skills (both written and verbal).
• Critical and analytical thinking.
• Familiarity with healthcare finance and insurance practices.
• Experience working with federal healthcare regulations.
• Attention to detail.
• Proficiency in operating across various platforms and displays.
• Ability to work efficiently and independently.
• Able to follow processes and procedures.