Medical Appeals Lead

Every immune system has a story to tell- the key is knowing how to listen. Our goal is to meaningfully improve people's lives by learning from the wisdom of their adaptive immune systems. It's a bold objective that we're uniquely built to achieve.

At Adaptive, you'll be challenged, you'll be inspired, and you'll be part of an innovative organization making a real impact on improving the quality of life globally. No matter what your role is, you'll find a diverse, team-driven, fun culture where your contributions truly count.

Position Overview

The Medical Appeals Lead is primarily responsible for collaborating with internal stakeholders and outside billing service to improve appeal success for medical and administrative appeals.

Responsibilities

• Collaborates with internal stakeholders and billing service to improve appeal success for medical and administrative appeals

• Assists with developing educational materials, training, and operational processes to support strong appeals positions

• Leads medical appeals team on appeal rationale for various clinical scenarios

• Develops strong and specific medical appeals utilizing key information from the patient's medical record, clinical scenario, scientific or medical publications/literature, and medical team

• Improves precision and specificity of administrative appeals and documentation in support

• Ensures timely appeal submissions and follow up

• Uses metrics to track, report, and improve appeals success

• Generate effective written appeals using well-researched logic to recoup reimbursement on incorrectly denied claims

• Appeal carrier denials through coding review, contract review, medical record review and payer interaction

• Utilize various resources to ensure correct appeal processes are followed and completed in a timely manner

• Demonstrate high level of expertise in management of complicated appealed claims, and utilize an analytical approach to resolving denials

• Recognize trends and patterns to proactively resolve recurring issues

• Communicate identified denial patterns to management

• Prioritize and process a large volume of denials while maintaining high quality of work

• Serve as an escalation point for unresolved denial issues

• Inform team members of payer policy changes

• Assist in training new employees as assigned

• Collaborate on special projects as needed

Requirements

• Medical background required, clinical/oncology experience preferred. Nursing or clinical experience preferred

• Bachelors Degree + 5 years experience or Master +3 years of experience in medical practice billing with exposure to working with denials, appeals, insurance collections and related follow-up

• Demonstrated success in achieving improved performance in clinical appeals and overall reimbursement for denied claims

• Customer service, reimbursement experience preferred

• Knowledge of Medicare, Medicaid, and Private Insurer Reimbursement Methodology

• Able to interpret and analyze detailed Medical policies

• Basic understanding of the benefits investigation process [deductible, out of pocket, benefits exclusions, etc.]

• Coding and billing experience in the office, hospital, or ASC settings

• Experience in a reimbursement-based call center environment preferred

• Experience with the prior authorization process for products/services

• Ability to communicate effectively both orally and in writing Adept at handling sensitive and confidential situations

• Must have ICD-10 and CPT coding assessment skills, CPC certification is preferred.

• Must demonstrate a solid understanding and ability to apply contract language in conjunction with a comprehensive understanding of claims denial appeal logic

• Ability to manage multiple tasks to completion in a dynamic office setting

• Effective and professional communication skills for engagement with both internal and external personnel

• Excellent written communication skills are required, including technical computer proficiency (Word, Excel, etc.)

• Flexible, team-player with ability to develop best practices for procedures on new assignments

• Strong attention to detail and meticulous data entry skills

Adaptive Biotechnologies is proud to be an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability. Equal Opportunity Employer/Veterans/Disabled

NOTE TO EMPLOYMENT AGENCIES: Adaptive Biotechnologies values our relationships with our Recruitment Partners and will only accept resumes from those partners whom have been contracted by a member of our Human Resources team to collaborate with us. Adaptive Biotechnologies is not responsible for any fees related to resumes that are unsolicited or are received by any employee of Adaptive Biotechnologies who is not a member of the Human Resources team.