Appeals and Authorization Representative - Catholic Health

Catholic Health is one of Long Island’s finest health and human services agencies. Our health system has over 16,000 employees, six acute care hospitals, three nursing homes, a home health service, hospice and a network of physician practices across the island.

At Catholic Health, our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence based practice to improve outcomes – to every patient, every time.

We are committed to caring for Long Island. Be a part of our team of healthcare heroes and discover why Catholic Health was named Long Island's Top Workplace!

The Appeals and Authorization Representative will perform activities to help facilitate appeals functions to include coordination of specific process and payment related activities.

Responsibilities include, but are not limited to the following:

• Review providers' requests for services and coordinate appeals management review.
• Generate an appeal letter to substantiate the medical necessity.
• Generate appeal letter for out of Network underpaid claims as compared to Fair Health rates when applicable.
• Prepare appeal letter for IDRE for denied and underpaid claims when applicable.
• Monitor denials as well as all financial metrics associated with front-end review process.
• Collect data, prepare analysis, and oversee communication tools (i.e. spreadsheets) for governmental and non-governmental agencies
• Review all cases received from Patient Access to verify that the insurance pre-certification/notification process has been completed in order to meet contractual obligations.
• Manage/follow-up on appeal status with the Managed Care Payors or regulatory agencies, as needed or requested.
• Notify Department Leadership of potential missed timeframes for submission and follow-up on responses and escalate cases as appropriate.

• Serve as a liaison between patient account services, physicians. Develop/validate daily work lists for Appeals Manager.
• Assist with all insurance and regulatory audits and provide information to Manager related to inaccurate and/or missing documentation as applicable.
• Provide support for ongoing projects as required
• Meets productivity standards.
• Attend meetings as required and participates on committees as directed. 
• Perform other related duties as assigned or requested. 

REQUIREMENTS AND QUALIFICATIONS

Education/Experience

• Knowledge of CPT and ICD 10 coding with excellent written skills
• Coding Certification preferred
• Minimum of 3 years Healthcare experience

SKILLS

• Sound knowledge and skill in the use of personal computer and software for word processing, spreadsheet and database applications required. 
• Ability to effectively communicate with all levels of hospital staff in a verbal and written manner; demonstrated ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
• Demonstrates a courteous and professional demeanor, team spirit and the ability to work in a collaborative, effective manner.
• Ability to utilize critical thinking and apply sound clinical judgment and assessment skills for decision-making.

KNOWLEDGE

• Maintain knowledge of requirements by third party payers, regulatory agencies, and managed care entities concerning levels of care, continuity of benefits and medical necessity guidelines.

• Knowledge of managed care and the current standards and trends of patient care, best practices, management tools.

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, or other forms of compensation that may be applicable to this job and it does not include the value of benefits.

At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.