Appeals Specialist Resume Samples

The role of an Appeals Specialist is to log, track and process the appeals and grievances that are placed or escalated to them. Core duties and tasks listed on the Appeals Specialist Resume include – reviewing patient record, contacting patient or customer to gather information, communicating disposition of the case, conducting patient research as a means to evaluate and close the appeal, building case files for each of the received grievance, taking regulatory actions, reporting to the supervisor or manager-in-charge, and searching for evidences to support appeal arguments.

To become successful in this career path, depicting these skills will prove to be useful – collecting and researching skills, ability to identify and resolve issues, oral communication skills, demonstrable amount of accuracy and thoroughness, ability to support affirmative action, and a good knowledge of HIPAA guidelines. Education requirements may vary from employer to employer, but it is commonplace to have a Bachelor’s degree in Hospital or Business Management among applicants. Nursing degree is also preferred.

Appeals Specialist Resume example

Appeals Specialist Resume

Summary : To obtain an Administrative position that will allow to fully utilize communication, organizational, problem solving skills, and general office skills to contribute to greater office efficiency and productivity.

Skills : Customer Service Rep, Teller, Supervisor, trainer, Data Entry, Secretary/Receptionist.

Description :

    1. Performed in depth analysis of inquiries and complaints and compose appeal letters for clients.
    2. Obtained Medical Records and send to various doctors as requested in addition to adjusted claims.
    3. Documented in patient accounts with actions taken to resolve issues.
    4. Scaned hard copy medical records and correspondence to convert to electronic files.
    5. Reviewed disputed signatures for appeal letters and assist in finding any discrepancies.
    6. Took on leadership roles, met productivity and department goals.
    7. Provided auditing support for clinical staff including making verbal and written communications to members regarding appeal determinations.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Business Management


Sr. Appeals Specialist Resume

Summary : Adaptable, independent and responsible, punctual and a team player. Along well with others as well as co-workers. Able to communicate in a clear, concise, understandable manner, and listen attentively to others.

Skills : Microsoft Windows Operating SystemsMS OfficeData Entry/10 Key 12,000 Ksph/Typing.

Description :

    1. Responsible for daily handling of casework, including processing of new cases, coordinating open cases to resolution and entering closing casework notes to resolve cases.
    2. Researches issues utilizing systems and clinical assessment skills, knowledge and approved Decision Support Tools in the decision making process regarding health care services and care provided to members, and Marketplace enrollment issues.
    3. Assures timeliness and appropriateness of all case resolutions according to state and federal and Healthcare guidelines.
    4. Requests and obtains enrollment history, claims history and/or invoices as appropriate to assist with research.
    5. Collaborates with Manager, Government Contracts and other team members to determine appropriate responses.
    6. Works with Enrollment, Member Services and Premium Billing to resolve member complaints regarding their enrollment.
    7. Prepares/Coordinates responses to member complaints/inquiries to regulatory agencies and or plan partner.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Senior
Education
Education
Diploma


Jr. Appeals Specialist Resume

Summary : Over 12 years of successful management and leadership experience with a reputation for meeting the most challenging organizational goals and objectives. Dedicated and focused at prioritizing, completing multiple tasks simultaneously and following through to achieve project goals.

Skills : Microsoft Office, Government Databases, Social Media.

Description :

    1. Acquired necessary information to thoroughly analyze, investigate and provide a clear and concise explanation of why a claim was denied or how a claim was adjudicated within strict timeframes.
    2. Communicated with the plan participant daily.
    3. Identified and made recommendations on how on how adjudication system and or processes can be enhances.
    4. Prepared and referred cases for external review as mandated.
    5. Provided all administrative related information and routed accordingly for proper review.
    6. Ability to read, interprets, and analyzes documents such as reports, guidelines, plan documents and summary plan descriptions.
    7. Researched and resolved payment related issues and properly identify root cause of appeal.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Business Management

Appeals Specialist/Analyst Resume

Summary : Extremely hard working and eager to utilize the skills. Excellent organizational skills and very dependable. Proficient in Microsoft Office.

Skills : Communication skills, Artistic, Fundraising, Creative writing, Research, sales, Marketing.

Description :

    1. Processed MCO member appeals for Medicaid and Medicare lines of business.
    2. Coordinated with upper level management such as Medical Directors with level 1, 2 and 3 appeals in order to represent the members' appeal accurately.
    3. Followed internal policies and procedures to ensure timely and accurate appeals decisions were made.
    4. Met all timelines, made sure that all necessary research was completed, and that all information in the appeal files was accurate.
    5. Ensured file contents were in compliance with internal and external auditing standards.
    6. Assured appeals process was in compliance with both internal and external rules and regulations.
    7. Advocated for members to ensure that they understood their appeal rights and had a clear understanding of the appeal process.
    8. Assisted management in improving appeals processes in order to reduce transportation appeals by 90%.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
Bachelors Of Science

Appeals Specialist III Resume

Summary : Extensive experience with clients in many areas of Healthcare Administration, communications, and insurance billing. Recognized for high ethical standards in all work performed. Consistently made significant contributions to corporate goals for business growth and profits.

Skills : Project Management, Analytics, Microsoft Office Professional Suite, Omega, SharePoint, Team Leader.

Description :

    1. Worked to resolve all client and physician issues for a Third Party Administrator.
    2. Created all training material for employees.
    3. Performed adjustments, investigated claims, and provided telephone coverage for customer service department.
    4. Compared data on claim applications with policy statements and other company records to ascertain completeness and validity of claim.
    5. Worked closely with medical offices and personnel to ensure that complaints were resolved quickly and accurately.
    6. Reviewed and investigated appeals on behalf of over 300 payers and 20,000 patients.
    7. Committed to the assistance and support of others while maintaining a cheerful and helpful attitude.
    8. Responsible for the training for all new Appeals Specialists on all Regulations and Operations for the State Department of Insurance in over twenty five States.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Information Technology

Appeals Specialist II Resume

Summary : Excited for an opportunity where can use knowledge and expertise in Human Resources with a focus on customer service, keen attention to detail and continuous improvement. Works well by collaborating with others, builds rapport with internal and external customers, acts with integrity and initiates improvement ideas to help with team morale and motivation.

Skills : Microsoft Excell, Microsoft Outlook, Typing, Problem Solving, Multi-tasking, Communication, Interpersonal, Microsoft Word.

Description :

    1. Answered incoming calls and respond to written correspondence from members requesting to appeal services or cost shares for all lines of business.
    2. Accountable for researched the accuracy of claims processing and denials of authorization requests for medical related services.
    3. Responsible for verifying appeal rights and preparing cases for review and determination within established guidelines and timeframes.
    4. Prioritized and managed caseload daily to ensure cases are handled timely, thoroughly and appropriately in an effort to meet all departmental metrics and regulatory requirements.
    5. Trained, coached and mentored new and existing staff and provide feedback on performance to ensure quality and accuracy.
    6. Operated with discretion and maintain confidentiality at all times.
    7. Collected and input data in applicable systems for accurate reporting.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Bachelor's Of Science

Appeals Specialist II Resume

Summary : Over 11 years total experience with medical review of home health care and hospital medical records. Over three years' recent experience with inpatient hospital Utilization Review and Appeals.

Skills : Typing 55 Wpm , IDX, Epic And Facets Knowlege.

Description :

    1. Reviewed files to determine whether all relevant information has been submitted.
    2. Identified and matched denied item(s) within the case file, the denial rationale presented by the Medicare contractor and arguments of appellants.
    3. Correctly matched denied items and arguments to Medicare policies.
    4. Identified whether the case required review by an independent physician consultant.
    5. Outlined pertinent facts and issues for review by independent physician consultants.
    6. Acquired all necessary information involved in case and rendered a determination based on the information.
    7. Used Internet and hard copy tools to research issues using federal laws and regulations relevant to CMS policies.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Psychology

Appeals Specialist I Resume

Headline : Implemented procedures and pursued additional tools to enhance work and company goals. Experience and skills have been used to guide others in a team atmosphere to achieve goals and decrease the accounts receivable.

Skills : Proficient In Microsoft Word, Excel, Power Point, Outlook; Multiple Health Insurance Websites; Medifax; NNPES Registry; Excellent Customer Service; Strong Interpersonal Skills; Experienced With All Standard Office Equipment.

Description :

    1. Reported to Regional Manager of Patient Accounts and was responsible for appealing commercial non-par payments for 14 states.
    2. Implemented procedures for non-par provider collections which became a model used to collect in all states.
    3. Worked diligently with other departments, insurance companies and outside vendors to collect payment of 84% or more on all billed charges.
    4. Generated correspondence or called patients and insurance companies to resolve accounts receivable.
    5. Generated monthly reports for review by regional and corporate management.
    6. Worked as a consultant to train a new Appeal Specialist and Corporate Employees.
    7. Assisted managers in covering employee absences in all departments.
Years of Experience
Experience
5-7 Years
Experience Level
Level
Executive
Education
Education
Business Writing

Appeals Specialist/Coordinator Resume

Summary : Appeals Specialist with 10 years of experience with corporate office practices and procedures. Skilled in project management, team leadership, and quality assurance, and data compilation. Proven verbal, written, and interpersonal skills coupled with extensive time management and organizational abilities essential to corporate goals in a high volume environment.

Skills : Outpatient and Inpatient records, Records Management, Billing and Collections Procedures.

Description :

    1. Processed Medicare Part B redetermination applications submitted by providers and benefices.
    2. Successful adjudication of claims and authorize payment to providers.
    3. Proficient in medical billing coding and terminology, ICD-9 codes and CPT interpretation.
    4. Maintained client confidentiality as set forth by HIPAA and adhered agreements and standards regarding ethical behavior and confidentiality.
    5. Handled customer inquiries, complaints, billing questions and payment extension/service requests.
    6. Calm angry callers, repair trust, locate resources for problem resolution and design best-option solutions.
    7. Composed and edited letters by using a matrix.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Associates In Paralegal

Appeals Specialist Resume

Summary : Reputation for displaying professionalism and integrity Reputation for providing great customer service to people under stress Reputation for ability to mentor and train new colleagues Learning and implying new techniques, systems, and procedures.

Skills : Microsoft Word, Microsoft Excel, Microsoft Outlook, Microsoft PowerPoint.

Description :

    1. Identified issues or trending and provider suggestions for resolution.
    2. Accurately and thoroughly documented the pertinent collection activity performed.
    3. Reviewed the account information and necessary system applications to determine the next appropriate work activity.
    4. Verified claims adjudication utilizing appropriate resources and applications.
    5. Performed appropriate billing functions, including manual re-bills as well as electronic submission to payers.
    6. Edited claims to meet and satisfy billing compliance guidelines for electronic submission.
    7. Managed and maintained desk inventory, complete reports, and resolve high priority and aged inventory.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
High School