Appeals Resolution Specialist

The Appeal Resolution Specialist is responsible for managing complex payer deferrals, denials, and appeals to support timely resolution and successful authorization outcomes. This role serves as a subject matter expert in researching payer decisions, identifying root causes, determining appropriate resolution strategies, and preparing accurate and comprehensive appeal submissions.

The Appeal Resolution Specialist collaborates with internal teams, payers, and other stakeholders to resolve funding barriers while ensuring compliance with payer requirements, organizational policies, and applicable regulatory guidelines. The position requires strong analytical skills, attention to detail, effective written and verbal communication, and the ability to independently manage complex cases through resolution.

Company Description:

At all levels, working at National Seating & Mobility provides the opportunity to directly impact our clients’ lives by giving them self-reliance and independence. Our teams are comprised of passionate individuals, dedicated to providing the best care to each client. We focus on abilities by leveraging technology and creating mobility solutions that are as unique as our client’s needs.

Working at National Seating & Mobility is an opportunity to build a meaningful career, while leaving a lasting impact on the lives of those we serve. Located in more than 40 states, we strive for diversity and offer an array of benefits including 401k, company paid Long Term Disability, and tuition reimbursement.

Duties and Responsibilities / Essential Functions:

1. Review and manage assigned deferrals, denials, and appeals to determine the appropriate course of action and ensure timely resolution.
2. Analyze payer correspondence, denial reasons, authorization requirements, medical documentation, and account history to identify the underlying cause of the payer decision.
3. Research payer policies, coverage criteria, contractual requirements, and applicable guidelines to determine appeal opportunities and resolution strategies.
4. Prepare clear, accurate, and persuasive appeal submissions supported by appropriate documentation and payer requirements.
5. Coordinate with internal departments to obtain missing or additional documentation necessary to support an appeal or resolve a deferral.
6. Communicate directly with payers, healthcare providers, and internal stakeholders to clarify requirements, address outstanding issues, and facilitate resolution.
7. Monitor appeal deadlines and payer response timeframes to ensure cases are worked within established requirements.
8. Perform appropriate follow-up throughout the appeal process and escalate complex or high-risk cases when necessary.
9. Maintain complete and accurate documentation of appeal activity, payer communication, decisions, and resolution outcomes within applicable systems.
10. Identify recurring denial and deferral trends and communicate findings to leadership to support process improvement initiatives.
11. Partner with operational, funding, billing, training, and quality teams to identify opportunities to reduce preventable denials and improve first-pass success.
12. Serve as a resource and subject matter expert regarding payer appeal processes, documentation requirements, and resolution strategies.
13. Maintain current knowledge of payer policies, regulatory requirements, and organizational procedures affecting authorization and appeals.
14. Meet established productivity, quality, timeliness, and resolution performance expectations.
15. Support special projects, audits, process improvements, and other departmental initiatives as assigned.
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Work Environment:

This job operates in a professional office environment. This role routinely involves standard office equipment such as computers, phones, printers, photocopiers, filing cabinets and fax machines.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is regularly required to sit; use hands repetitively to operate standard office equipment. The employee is frequently required to reach with hands and arms.

Required Education, Experience & Competencies:

·       High School Diploma or G.E.D. Required

·       Drug Test

·       Strong knowledge of healthcare payer requirements, authorization processes, denials, deferrals, and appeals.

·       Ability to interpret payer policies, medical documentation, correspondence, and coverage requirements.

·       Strong analytical and problem-solving skills with the ability to identify root causes and determine appropriate resolution strategies.

·       Excellent written communication skills with the ability to develop concise, well-supported appeal documentation.

·       Strong verbal communication and interpersonal skills when working with payers and internal and external stakeholders.

·       Excellent organizational and time-management skills with the ability to manage multiple cases and deadlines simultaneously.

·       High level of accuracy and attention to detail.

·       Ability to work independently, exercise sound judgment, and appropriately escalate complex issues.

·       Ability to identify trends and recommend opportunities for process improvement.

·       Proficiency with applicable payer portals, Microsoft Office applications, and other business technology.