Appeals Specialist (Full-time) - Restore Corporate Office

Pelham, Al

 

GENERAL PURPOSE:

To ensure timely response and successful intervention of denied claims. To keep abreast of current regulatory changes and provide pro-active education to reduce the number of medical record request and denied claims.

QUALIFICATIONS:

 Must be a registered therapist in good standing and meet applicable federal and state licensure requirements.

 A minimum of two (2) years rehabilitation experience preferred. Long-term care experience preferred.

 Supervisory experience, preferred

 Must be at least 18 years of age.

 Completion of secondary education.

 Able to communicate and train in a multi-disciplinary environment.

 Able to read, write and follow oral and written directions, and present ideas and training, at a level necessary to accomplish the job.

 Must be able to relate positively and favorably to customers and officials and work cooperatively with other Employees.

 Must meet all state and local health regulations and pass a post-employment exam, if required.

 Knowledgeable of the Medicare regulations and guidelines established by CMS.

 Must be capable of performing the Essential Job Function of this job, with or without accommodation.

ESSENTIAL JOB FUNCTIONS:

 Responsible for writing appeal letters for denied therapy and multi-discipline claims.

 Prepare letters to intermediaries requesting a hearing before an Administrative law judge.

 Conduct research and obtain information to support and strengthen a claim.

 Effectively, prepare a letter to the Appeals council in Washington, D.C. requesting reconsideration of a denied claim.

 Review and prepare claims to effectively present a case via tele-conference with Fair Hearing Officers.

 Review and prepare claims to effectively present a case in court to an Administrative law judge.

 Request information, as needed, from the clinicians to prepare for the case.

 Maintain a working knowledge of legal and ethical issues affecting the therapy practice.

 Research changes in current clinical trends.

 Develop positive relationships on behalf of the company with customers, government regulators, and the health care community.

 Assist with training bookkeepers and financial specialists to ensure correct identification of denials and MRR’S and timely processing.

 Conduct and participate in clinician education of the appeals and reimbursement process.

 Maintain professional competence through participation in continuing education programs and seminars.

 Manage the indemnification process and submit reports to Accouting as needed.

 Manage the Appeals process to ensure maximum success in overturning denied claims.

 Understand, comply with and promote rules regarding residents? rights.

 Other Duties: 

 Adhere to all company policies and procedures.

 Perform other duties as assigned.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Physical and Sensory Requirement (With or Without the Aid of Mechanical Devices):

Walking, reaching, climbing, bending, lifting, grasping, fine hand coordination, pushing and pulling, ability to distinguish smell and temperatures, ability to read and write, ability to communicate with personnel, patients, and outside agencies. Ability to present to groups and the ability to remain calm under stress.

 

Location: Restore Corporate Offices

245 Cahaba Valley Parkway Suite 200 Pelham, AL 35124

Restore's Corporate office is located in the Cahaba Valley Parkway area.