Clinical Appeals & Denials Specialist - Temp

About the Team:     

Sound Advisory Services provides high-quality concurrent and secondary case reviews and advisory services to hospital partners nationwide. Our unique approach includes both remote advisory services and the option for an onsite medical director of advisory services.

The Clinical Appeals and Denials Support Specialist (CADSS) will report to the Manager of Appeals & Peer to Peer Operations. Primary responsibility but not limited to- follow up on outstanding appeals at 30, 45, 60, and 75 intervals. Proficient in navigating and documenting within internal document system.   CADSS will access Insurance companies’ payer portals to ensure appeal has been processed, navigate site for necessary associated updates. Make outbound phone calls to insurance companies to ensure appeal receipt, outcome, and next course of action.  Documentation of all activity and updates to ensure timely notification of appeal outcomes and next steps. Hourly monitoring of the appeals queue to ensure clients appeal request are acknowledged, pertinent necessary data has been uploaded, and assigned to a physician advisor. Prepare Medical record for appeal writer. Provide as needed administrative and operational support for the Clinical Support Specialist.

• Investigating, tracking and documenting appeal outcomes
• Monitoring incoming client appeal portal and if necessary, professionally communicating with Client Case management
• Maintaining access to all insurance companies’ payer portals
• Maintaining access to all client EMRs and review EMR training material to become an expert in EMR navigation; preparing PDF extracts of key components of the EMR needed for physician advisor case review
• Providing administrative support to facilitate the completion of appeal letter requests including, but not limited to, creating cases, preparing the medical record for the appeal writer, confirming deadlines, printing and mailing final letters, and calling payers to confirm outcomes
• Resolving issues preventing physician advisors/ nurses from completing cases such as missing information, questions for case managers or hospital partner physicians, EMR access issues, etc.
• Monitoring and triage of appeal case requests to ensure target case completion deadlines are achieved
• Triaging calls during office hours and resolve client inquiries
• Preparing Excel spreadsheets as requested
• General office work (faxing, mailings, draft letters, order supplies & forms)
• Completing additional special projects as assigned

• Work Ethic - Dedication to getting the job done well and on time, regardless of circumstances, a can-do attitude
• Communication: The ability to speak, write, and listen clearly and consistently
• Relationship Building and Maintenance: The ability to create and nourish healthy, strong relationships, as the face of Sound
• Teamwork: Demonstrates the ability to pull people together into highly effective teams along with ability to work in a highly matrixed organization
• Critical Thinking: Demonstrates the ability to be proactive, anticipate needs; ability to make good decisions with incomplete, ambiguous information
• Adaptability - Demonstrates flexibility and a willingness to change as circumstances evolve and be coachable
• Resourceful - Proactive willingness to utilize available information and tools to figure things out, not afraid to ask questions when necessary
• Commitment - Demonstrates a dedication to the job, project, organization, customer/clients, and co-workers

• High School degree or GED or equivalent experience
• Strong interpersonal skills to handle sensitive situations and confidential information. Position requires demonstrated poise, tact, diplomacy, and good judgment
• Proficiency with Microsoft Office Suite, including advanced Outlook, Word, Excel, Visio, Microsoft Project and PowerPoint skills
• Excellent general office skills: computers, fax machines, printers, copiers, conference call set-up, scanners, mobile phone/email devices

• 2 years medical insurance/ revenue integrity/ hospital accounts receivable & payable/ third party denials and appeals management experience
• Ability to manage outbound phone calls for 8 hours
• Ability to multi-task and prioritize workload in a fast-paced environment