Claims & Appeals Specialist II

• is not intended to be all-inclusive;
• employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.

​ General Duties

• Maintains the utmost level of confidentiality at all times.
• Adheres to hospital and DHP policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Performs other duties as requested.
• Claims and Appeals Specialist II Duties and Responsibilities:
• Reviews claims appeal and makes recommendations regarding reprocessing/denial of payment.
• Research provider’s claims questions.
• Works closely with Provider Relations Representatives to assist with provider claim issues.
• Provides insight to potential claims payment issues.
• Notifies Compliance Officer for DHP of potential fraud and abuse.
• Research billing issues.
• Responds to providers regarding claims-related issues.
• coordination of benefit activities.
• Coordinates re-consideration of claims with DHP’s Third Party Claims Administrator
• Active member of bi-weekly claims meetings between DHP and DHP’s Third Party Claims Administrator. ​

E DUCATION AND / OR E XPERIENCE : ​

• High school diploma or general education degree (GED); or associate’s degree (A. A.) or equivalent from two-year college or technical school; three to five years related experience and/or training; or equivalent combination of education and experience.
• 3 -5 years’ experience of coding in an acute care hospital setting preferred