1+ months

Medical Appeals Specialist Lead

Myrtle Point, OR 97458
Regular Full Time

The Medical Appeals Specialist Lead supports the Medical Appeals management and a team of Medical Appeals Specialists responsible for administrative support for appeals process such as reconciliation of appeals received from the Provider/MAC, coordination of appeals documents and activities; and serving as a point of contact between the MAC and other internal departments within Performant. As the Medical Appeals Specialist, you will join a team of experienced medical auditors. You will work in a fast paced and dynamic environment and be part of a multi-location team.  

Primary Job Duties:

Medical Appeals Specialist
Perform specialist duties for smaller scope and/or as back-up for team members as necessary for time off and to meet business needs. 
Provide administrative support for activities related to Appeals processes.
Coordinate calls between Performant team members and 3rd party representatives, such as Physician to Physician discussions.
Support case file building to ensure appropriate documentation and information is appropriately available to support hearings, physician-to-physician calls, and other appeals activities.
Maintain appeals statuses and activities updating applicable systems and trackers.
Facilitation of communication updates in appeals process applicable based upon stage, preparation necessary, and outcomes, which may include, but not limited to:
Documenting call discussion, decisions, and outcomes in accordance with department procedures 
Documenting findings referencing the appropriate policies and rules
Generating letters articulating outcomes as needed
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
Attend internal meetings as well as appeals meetings, calls, hearings as scheduled applicable to assigned scope. 
Work with the project team to minimize appeals

Lead Duties
Successfully cross-train and maintain current on all department processes to be able to support all contracts/areas in the Appeals Specialist functions and serve as back-up for team members as may be necessary.
Trains new Appeals Specialists, as well as trains Appeals Specialists in any changes to workflow, procedures, tools, etc. 
Provides support to team members by providing answers to questions, as well as serves as first point of escalation for issues that may arise. 
Lead by example and demonstrates knowledge and expertise in carrying out scope of responsibilities through achieving excellent performance results, as well as compliance, attendance, and behavior
Proactively supports research, analysis and resolution of questions and issues that arise or as assigned by management
Assist management in developing and maintaining tools and resources for training and/or communicating changes in requirements, systems, processes, and procedures, as well as supports transition and adaptation by the team in a positive and effective manner.
Perform audits and provide reports to management as may be applicable. 
Support management in review of team productivity and identify potential issues and recommendations to management.
Support other projects as assigned by management
Support management in the coordination, distribution, and completion of teams volume

Apply appropriate Medicare policy and rules as may be applicable to perform job duties
Follow policies and procedures pertinent to the RAC review process
Keep abreast of medical practice, changes in technology, and regulatory issues that may affect the RAC contract applicable to the job function
Is punctual, works assigned schedule, maintains regular good attendance. 
Follows and complies with company and departmental policies, processes, and procedures.
Responsible for utilizing resources to ensure compliance with client requirements, HIPAA, as well as applicable federal or state regulations.
Successfully completes, retains, applies ,and adheres to content in required training as assigned 
Consistently achieve or exceed established metrics and goals assigned.
Demonstrates Performant core values in performance of job duties and all interactions.
Correct areas of deficiency and oversight received from quality reviews and/or management.

Other Duties
Performs other duties as assigned to meet business needs.


*Note - All employees and contractors for Performant Financial may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times.  Violations to Performants policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.

Required Skills and Knowledge:

Experience with ICD-9, CPT-4 or HCPCS coding.
Knowledge of the Medicare program, particularly the coverage and payment rules.
Ability to maintain high quality work while meeting strict deadlines.
Not currently sanctioned or excluded from the Medicare program by the OIG.
Knowledge of claims processing and appeals processes.
Strong knowledge of medical documentation.
Strong office technology skills; Can work independently using standard office computer and applications  (e.g. MS Office Suite Word/Excel/Outlook, Teams, PDF, phone, etc.) and adapts quickly to using new applications and tools.  
Experience using a case-management system/tools to review and document findings.
Excellent written and verbal communication skills.
Effective skills in managing multiple assignments, organizing and prioritize workload, and problem solving.
Effectives works independently and with team members.
Courteous, professional, and respectful attitude with ability to maintain professionalism and composure in difficult interactions or conflict.
Flexibility to handle any non-standard situations that may arise.
Demonstrated ability to serve as a positive role model for other staff.
Ability to effectively share information and train others for better results, as well as respond to inquiries and provide constructive feedback effectively.
Strong verbal and written communication skills; including excellent phone and email etiquette.
Strong problem-solving skills and applies good judgment and decision-making capabilities.
Ability to consistently perform job responsibilities with successful outcomes under minimum supervision.

Ability to obtain and maintain client required clearances as well as pass company regular background and/or drug screening.
Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety& ergonomics, confidentiality, and dedicated work focus without distractions during work hours.

Physical Requirements:

**NOTE: Must be able to meet requirements for and perform work assignments in accordance with Company policies and expectations on a home remote basis (and must meet Performant remote-worker requirements)until at which time staff may be notified and required to work from a Performant office location on an ad-hoc or periodic basis.

Basic office equipment required to perform remote work is provided by the company.

Job is performed in a standard busy office environment with moderate noise level (or may be home-office setting subject to Company approval and Teleworker Agreement), sits at a desk during scheduled shift, uses office phone or headset provided by the Company for calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard, and uses a mouse.

Reads and comprehends information in electronic(computer) or paper form (written/printed).
Sit/stand 8 or more hours per day; has the option to stand as needed while on calls; reach as needed to use office equipment.
Consistently viewing a computer screen and types frequently, but not constantly, using a keyboard to update accounts.
Consistently communicates on the phone as required primarily within the department and company and may include client contacts or other third-party depending on assignment; headset is also provided.
Occasionally lift/carry/push/pull up to 10lbs.

Education and Experience:
High School diploma, GED, or equivalent combination of education and experience. 
4+ years relevant experience health care claims that demonstrates expertise in Medicare claims data such as for medical billing experience for an Insurance Company or hospital demonstrating depth of knowledge and capability required for the position.
1+ years directly relevant experience related to appeals processes applicable to the role
Relevant experience demonstrating leadership experience and capacity for functional area (e.g. direct or indirect responsibility for training, subject matter expert for team, or other scope of responsibility for supporting and contributing to success of others in a team). 
Claim processing experience


Other Requirements:
Performant is a Government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and clearances(as applicable).
Must submit to and pass pre-hire background check, as well as additional checks throughout employment.
Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors, nor on state/federal debarment or exclusion lists.
Must submit to and pass drug screen pre-employment (and throughout employment).
Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company.

Employment VISA Sponsorship is not available for this position

Job Profile is subject to change at any time.


Performant Financial Corporation is an Equal Opportunity Employer.
Performant Financial Corporation is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.



Sys.Application.initialize(); //


Posted: 2022-05-04 Expires: 2022-09-11
Analytics, audit, and recovery services for healthcare, government and student loans.

Before you go...

Our free job seeker tools include alerts for new jobs, saving your favorites, optimized job matching, and more! Just enter your email below.

Share this job:

Medical Appeals Specialist Lead

Performant Financial
Myrtle Point, OR 97458

Join us to start saving your Favorite Jobs!

Sign In Create Account
Powered ByCareerCast