Appeals Analyst

🔥 4 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🧐 Analyst

🚫👨‍🎓 No degree required

👻 Ghost score 10%

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Vālenz® Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2004

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Vālenz® Health is a comprehensive health plan solutions provider that offers a fully integrated platform designed to simplify the complexities of healthcare for employers, payers, providers, and members. The company focuses on enhancing quality and lowering costs through data-driven insights, member navigation, provider networks, and robust claims management. By connecting various stakeholders in the healthcare ecosystem, Vālenz aims to improve health outcomes and streamline the healthcare experience for all involved.

📋 Description

• Review provider appeals according to SOPs, SLAs, plan documents, network agreements, and contract requirements • Compare reimbursement findings for in- and out-of-network appeals • Calculate and propose initial settlement offers using claim history, pricing tools, and relevant data • Negotiate settlement terms and complete agreement templates for provider review • Support compliance with ERISA and applicable federal and state regulations • Maintain detailed documentation of appeal research, negotiations, approvals, and outcomes • Record finalized agreements for future reference and compliance • Ensure claims are accurately priced according to finalized agreement terms • Communicate appeal statuses and resolutions to clients and providers • Prepare and issue denial determinations when appropriate • Coordinate approvals exceeding delegated authority • Use Zendesk, internal claims systems, Microsoft Outlook, Microsoft Teams, and other departmental software • Perform other duties as assigned

🎯 Requirements

• 2+ years of healthcare claims, provider appeals, reimbursement, revenue cycle, or medical billing experience • Knowledge of CPT-4, HCPCS, Revenue Codes, DRG, and ICD-10 coding • Knowledge of the No Surprise Act, ERISA guidelines, and related legislation • Highly detail-oriented with ability to identify discrepancies and ensure accurate results • Experience analyzing out-of-network claim appeals using claim pricing tools and data • Knowledge of Medicare reimbursement methodologies • Experience reviewing Explanation of Benefits (EOBs) • Ability to interpret contracts and Plan documents • Experience with provider negotiations and evaluating counteroffers • Experience with Microsoft Outlook, Teams, and Excel • Dependable and committed to maintaining a reliable work schedule while meeting productivity and performance expectations • Associate or bachelor’s degree in healthcare administration or related field is a plus • CPC Certification is a plus • Experience with international plans and self-funded insurance is a plus • Knowledge of the Independent Dispute Resolution (IDR) process is a plus • Must be US based • Reliable internet connection and quiet, distraction-free workspace • Adherence to company security protocols, including VPNs, secure passwords, and company-approved devices/software

🏖️ Benefits

• Competitive benefits package with generous employer subsidies • Flexible and remote working options • 401k with generous employer match and immediate vesting • Personal and professional development opportunities • Supportive family benefits, including paid leave for new family members • Companywide philanthropic program, Valenz Communities Connection • Necessary equipment provided • Generously subsidized company-sponsored Medical, Dental, and Vision insurance • Access to Healthcare Blue Book and KISx Card services • HSA, FSA, and DCFSA spending account options • Flexible working environment • Generous Paid Time Off, including vacation, sick leave, and paid holidays • Employee Assistance Program with professional counseling, referrals, and additional services • Paid maternity and paternity leave • Pet insurance • Employee discounts on phone plans, car rentals, and computers • Community giveback opportunities, including paid time off for philanthropic endeavors

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