[Hiring] Appeals Analyst @Valenz

Role Description

As an Appeals Analyst, you’ll review provider appeals by applying established procedures, service level agreements, plan documents, and network contract requirements to ensure accurate and timely claim determinations. You’ll calculate and negotiate settlement offers, prepare agreement documentation, issue denial determinations when appropriate, and coordinate approvals that exceed delegated authority while maintaining compliance with ERISA and applicable federal and state regulations. You’ll also maintain detailed records of appeal activity and outcomes, ensure claims are priced according to finalized terms, communicate statuses and resolutions with clients and providers, and utilize Zendesk, internal claims systems, Microsoft Outlook, and Microsoft Teams to support efficient case management and workflow.

Things You’ll Do Here

• Review appeals received from providers while adhering to established Standard Operating Procedures (SOPs), Service Level Agreements (SLAs), and maintaining timely communication with clients and providers.
• Compare reimbursement findings against applicable plan documentation, network agreements, and contract requirements for in- and out-of-network appeals.
• Calculate and propose initial settlement offers based on claim history, other pricing tools, and relevant data.
• Complete agreement templates detailing negotiated terms and forward them to providers for review.
• Support compliance with ERISA and applicable federal and state regulations.
• Maintain detailed documentation of appeal research, negotiations, approvals, and outcomes.
• Record and document finalized agreements for future reference and compliance.
• Ensure claims are priced accurately, reflecting the terms stipulated in finalized agreements.
• Communicate regularly with clients to provide updates on appeal statuses, outcomes, and other pertinent information.
• Prepare and issue denial determinations based on appeal reviews, ensuring compliance with applicable policies and guidelines.
• Coordinate with clients when approvals exceed delegated authority in accordance with established policies and standard processes.
• Utilize Zendesk, internal claims systems, Microsoft Outlook, Microsoft Teams, and other departmental software to manage appeals, documentation, and communication.
• Perform other duties as assigned.
• Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

Qualifications

• 2+ years of healthcare claims, provider appeals, reimbursement, revenue cycle, or medical billing experience.
• Knowledgeable in CPT-4, HCPCS, Revenue Codes, DRG, and ICD-10 coding for accurate claims review, pricing, and payment validation.
• Knowledge of the No Surprise Act, ERISA guidelines, and related legislation.
• Highly detail-oriented with the ability to identify discrepancies and ensure accurate results.
• Proficient in analyzing out-of-network claim appeals, utilizing claim pricing tools and data to assess reimbursement accuracy and support appeal determinations.
• Knowledgeable of Medicare reimbursement methodologies.
• Proficient in reviewing Explanation of Benefits (EOBs) to identify payment discrepancies and support claim appeal resolution.
• Ability to interpret contracts and Plan documents to support accurate claim adjudication and appeal determinations.
• Experienced in provider negotiations and evaluated counter offers to achieve timely and cost-effective claim settlements.
• Experience with Microsoft Outlook, Teams, and Excel.
• Dependable and committed to maintaining a reliable work schedule while meeting productivity and performance expectations.

Requirements

• A plus if you have an Associate or bachelor’s degree in healthcare administration, or related field.
• CPC Certification.
• Experience with international plans and self-funded insurance.
• Knowledge of Independent Dispute Resolution (IDR) process, including applicable reimbursement guidelines and compliance requirements.

Benefits

• Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
• Spending account options: HSA, FSA, and DCFSA.
• 401K with company match and immediate vesting.
• Flexible working environment.
• Generous Paid Time Off to include vacation, sick leave, and paid holidays.
• Employee Assistance Program that includes professional counseling, referrals, and additional services.
• Paid maternity and paternity leave.
• Pet insurance.
• Employee discounts on phone plans, car rentals and computers.
• Community giveback opportunities, including paid time off for philanthropic endeavors.