Valenz® Health simplifies the complexities of self-insurance for employers through a steadfast commitment to data transparency and decision enablement powered by its Healthcare Ecosystem Optimization Platform. Offering a strong foundation with deep roots in clinical and member advocacy, alongside decades of expertise in claim reimbursement and payment validity, integrity, and accuracy, as well as a suite of risk affinity solutions, Valenz optimizes healthcare for the provider, payer, plan, and member. By establishing “true transparency” and offering data-driven solutions that improve cost, quality, and outcomes for employers and their members, Valenz engages early and often for smarter, better, faster healthcare.
About Our Opportunity
As an Appeals Analyst, you will resolve of out-of-network, RBP, and related appeals. This encompasses not only negotiating reimbursement rates but also evaluating, denying, or settling appeals. You'll comply with industry guidelines and contracts, while liaising with our clients. Your contribution will be pivotal in analyzing appeals, conversing with providers, and determining the fairness and justification of claim counteroffers.
Key Responsibilities:
Receive, review, and address appeals from providers, ensuring that all appeals are processed in accordance with ERISA, plan guidelines, and other applicable regulations.
Reviews and evaluates provider counteroffers on claims, analyzing their legitimacy to ensure they're justified, equitable, and aligned with the best possible outcome for all parties.
Engage in negotiations with providers to achieve optimal results for clients, sometimes necessitating a direct denial or alternative negotiations.
Calculate and propose initial settlement offers based on claim history, other pricing tools, and relevant data.
Complete agreement templates detailing negotiated terms and forwards them to the provider for review.
Follow up on outstanding agreements to ensure timely closure.
Records and documents finalized agreements for future reference and compliance.
Ensures that claims are priced accurately, reflecting the terms stipulated in the finalized agreement.
Engages in regular communication with clients to update them on appeal statuses, outcomes, and other pertinent information.
Utilizes support software, such as Zendesk, ensuring adherence to all SLAs and ensuring efficiency and accuracy in communication.
Maintains strict compliance with company policies, procedures, and relevant regulations.
Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.
What You’ll Bring to the Team:
2+ years in analyzing, denying, or settling out-of-network appeals.
Proficient in CPT-4, HCPCS, Revenue, DRG, and ICD-10 coding for accurate claim reviews.
Knowledge of the No Surprise Act, ERISA guidelines, and related legislations.
Proven negotiation skills with providers for claim adjustments and counteroffers.
Strong analytical ability for evaluating claims using pricing tools and past data.
A plus if you have:
Experience with international plans
Experience in self-funded insurance
Where You’ll Work
This is a remote role.
Why You Will Love Working Here
We offer employee perks that go beyond standard benefits and compensation packages – see below!
At Valenz, our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. We want everyone engaged within our ecosystem to be strong, vigorous, and healthy. You’ll find limitless growth opportunities as we grow together. If you're ready to utilize your skills and passion to make a significant impact in the healthcare self-funded space, Valenz might be the perfect place for you!
Perks and Benefits
At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.
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