Appeals Analyst Resume Sample
Arnaldo Cummerata
338 Herzog Street,
Dallas,
TX
+1 (555) 105 3373
Work Experience
Senior Appeals Analyst
01/2018
-
PRESENT
Dallas, TX
- 3 – 5 years related experience and/or training; or equivalent combination of education and experience
- Working knowledge of claims and plan/policies
- Work independently in a fasted paced environment
- One to three years’ experience in physician medical billing with emphasis on research and claim denials
- Relevant, progressive experience in the area of specialization
- Serve as primary analyst of managed care information, such as health plan specific policies, to internal departments
- Conduct research to assist in development of policies and procedures, manuals and other internal documentation when necessary
- Maintain fee schedule and contract database by collecting client contracts and loading terms and preparing fee schedules
Appeals Analyst
06/2015
-
09/2017
Philadelphia, PA
- Analyze payment data related to client manage care contracts to ensure payor compliance. Communicate results to leader
- Research managed care contracts for negotiation purposes when necessary
- Relevant, progressive experience in the area of specialization
- Researches and resolves all appeals and any correspondence in clear and concise written form, maintaining compliance with state and federal time frames and requirements
- Independently assess, investigates and resolves difficult issues to achieve appellant satisfaction by utilizing company and industry knowledge of operational areas and all established policies and procedures
- Track appeals in the access data base to ensure specific turnaround time for responses and provide data for state required or requested reports
- Gather, compile and Produces monthly/quarterly reports on the grievance and appeals process for carriers and management including, but not limited to, number of appeals by categories, number of denials upheld and adjusted and timeframes met
- Provide feedback to service teams and management in an effort to educate and reduce overall appeal volume
Grievance / Appeals Analyst
12/2009
-
04/2015
San Francisco, CA
- Prepare and present appeal cases to Review Committee
- Overall management of Regulations, which includes rulemaking, information collection authorization and renewal, and Federal Register notices
- Serve as the project manager and principal drafter of rules
- Responsible for Director and Assistant Secretary decisions on, and other dispositions of, appeals filed by the oil, gas, coal, solid minerals, and geothermal industries under Title 30 of the Coe of Federal Regulations, Part 1290
- Provide internal guidance on statutes, regulations, and agreements governing rentals and royalties due the United States and Indian mineral interest owners
- Lead rulemaking projects; and settlement of rental and royalty disputes
- Prepares Director decisions on appeals of Office of Natural Resources Revenue orders regarding oil, gas, coal, solid mineral, and geothermal production reporting, royalty reporting, and royalty payment
Education
Pepperdine University - Encino Graduate Campus
2004 - 2009
School's Degree in Management
Professional Skills
- Demonstrate excellent organizational and time management skills resulting in a well balanced workflow
- Excellent interpersonal skills (i.e. active listening)
- Strong research, investigative, analytical and problem solving skills
- Excellent verbal and written correspondence skills
- Consistently exercises critical thinking skills or use logic and reasoning to assess and resolve problems
- Grievance & Appeals analyst experience and 3-5 years’ experience working in grievances and appeals, claims, or customer service
- Intermediate computer skills with Microsoft Outlook, Word and Excel
How to write Appeals Analyst Resume
Appeals Analyst role is responsible for research, microsoft, credit, training, database, analysis, insurance, compliance, events, government.
To write great resume for appeals analyst job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Appeals Analyst Resume
The section contact information is important in your appeals analyst resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Appeals Analyst Resume
The section work experience is an essential part of your appeals analyst resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous appeals analyst responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular appeals analyst position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Appeals Analyst resume experience can include:
- Strong analytical skills, experience in case or grant management required
- Utilize specialty resources effectively to include internal and external clinical, vocational and legal experts, as appropriate
- Prior experience FEMA required in appeals
- Demonstrate industry leading customer service internally and externally
- Demonstrate sound judgment in the development of differentiated appeals plans leading to optimal outcomes
- Evaluates effectiveness of existing policies and procedures
Education on an Appeals Analyst Resume
Make sure to make education a priority on your appeals analyst resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your appeals analyst experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Appeals Analyst Resume
When listing skills on your appeals analyst resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical appeals analyst skills:
- Utilize effective documentation standards that support a strong historical record of actions taken on the account
- Work effectively in an open floor environment
- Knowledge of smartphone apps, MS Office, Data Information System & Time Management Skills
- Minimize internal inaccuracies resulting in false denials to increase our revenue, streamline our operations, and to enhance the patient experience
- Experience working with managed care claims and appeals for health care professional services (physicians and other health care professionals)
- Demonstrated business writing proficiency
List of Typical Experience For an Appeals Analyst Resume
1
Experience For Denials / Appeals Analyst Resume
- Conducts detailed root cause analysis, including tracking and trending of errors and omissions that led to escalated complaint and makes recommendations to avoid future appeal occurrences
- Identifies refresher/enhancement training opportunities for division and/or enterprise employees to reduce and/or eliminate appeals and administrative exceptions. Communicates opportunities to Quality and/or Training departments and works with Supervisors to share knowledge and provide guidance
- Assists in the development of new/less experienced staff through mentoring, coaching and assisting them in the proper handling of appeal cases
- Assists with running and validating reports for the team
- Works with Quality and/or Training to develop and often deliver refresher training workshops to business teams on proper appeal handling
- Knowledge of insurance claim and membership systems required
- Knowledge of medical terminology, COB, Medicare procedures required
2
Experience For Grievance / Appeals Analyst Resume
- Knowledge of Claims Policy guidelines required
- Reviews incoming appeals to determine whether applicants to the PA program have filed sufficient information to constitute an appeal according to statutory requirements
- Researches applicable statutes, regulations, and policy related to the subject matter of the appeal
- Drafts appeal responses for Regional Administrator review and signature
- Coordinates with State, Local and Federal Officials on proposed policy and procedures changes, enhancements, additions, and deletions and their implementation
- Reviews incoming appeals and/or audits to determine whether applicants to the PA program have filed sufficient information to constitute an appeal according to statutory requirements
3
Experience For Grievance & Appeals Analyst Resume
- Review denial letter and original project worksheet for validate reason for denial or appeal for payment
- Superior customer service skill set, ability to listen, facilitate and negotiate problems
- 35 wpm typing
- Researches applicable statutes, regulations, and policy related to the subject matter of the appeal/audit
- Drafts responses for Regional Administrator review and signature
- Coordinate and formulate with project team members to gather additional documentation/information about the project
- Provide a rebuttal to the denial
4
Experience For Senior Appeals Analyst Resume
- Research and review relevant regulations and policies that support eligibility or denial
- Interact with regulatory and technical team as necessary for outcome
- Maintain and track caseload and track in management information system
- Keep Sector Lead, Task Force Lead, Project Lead, Team Lead & Group Lead informed on issues, problems & resolutions
List of Typical Skills For an Appeals Analyst Resume
1
Skills For Denials / Appeals Analyst Resume
- Utilize specialty resources effectively to include internal and external clinical, vocational, and legal experts, as appropriate
- Experience working in grievances and appeals, claims, or customer service
- Experience in complex claims processing necessary
- Overcome objections that prevent payment of the claim and gain commitment for payment through concise and effective appeal argument
- Experience in disability claims
2
Skills For Grievance / Appeals Analyst Resume
- Demonstrated collaboration and ability to partner inter-departmentally
- Coordinating with Federal, State, Tribal, or Local stakeholders during the appeals/audit process
- Coordinating with Federal, State, Tribal, or Local stakeholders during the appeals process
- Performing reviews of Public Assistance appeals and/or audits in regards to applicable Local, Tribal, State, or Federal laws, policies, and regulations
- Drafting appeals/audits' responses and requests for information for review within required time frames
3
Skills For Grievance & Appeals Analyst Resume
- Analyzing appeals with applicable Local, Tribal, State, or Federal laws, policies, and regulations
- Drafting appeals' responses and requests for information for review or signature by senior leadership
- Speak on phone throughout a daily assigned shift (with opportunity to alternate between sitting and standing if necessary)
- Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues
- Familiarity with medical coding and medical terminology
4
Skills For Senior Appeals Analyst Resume
- Available to respond to patient/third party requests during scheduled shifts
- Leads, participates in, and advises rule-making teams
- Provides direct feedback to appropriate parties as required on claim handling
- At hearings, Responsible for addressing questions posed by the Member's representatives
- Contacts customers to gather information and communicate disposition of case; documents interactions
- Generates written correspondence to customers such as members, providers and regulatory agencies
- Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement
- Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims
- Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs
5
Skills For Grievance / Appeals Analyst, / II Resume
- Identifies barriers to customer satisfaction and recommends actions to address operational challenges
- Manage and diffuse irate callers
- Communicate problematic variances, delays, and any other issues impacting reimbursement to management, contracting, payers and other internal and external stakeholders
- Complete special projects as assigned by the Supervisor of Denials or Manager of Coding and Compliance, accurately, without need of supervision and in a timely manner
- Collect Denied Reimbursement due to Dreyer Medical Clinic from Federal/State/Local Regulations and Contractual Obligations
6
Skills For Core Appeals Analyst Resume
- Perform analysis of denied claims in order to determine appropriate course of action.Process appeals in a timely fashion in accordance with payer guidelines and Dreyer Medical Clinic's policies and procedures
- Review technical and clinical denial arguments for reconsideration on top dollar accounts, including both written and telephonically through resolution process
- Identifies, analyzes and researches denials root causes and trends assists in the development of corrective action plans for resolution of denials
- Identify contract protection that can be leveraged to overturn denials
- Identify problem accounts/processes/trends and escalate as appropriate
- Identifies and communicates contract interpretation issues and language discrepancies to leadership as appropriate
7
Skills For Grievance / Appeals Analyst Ld-eagan MN Resume
- Identifies Payer company trends and communicates trends to supervisor for further action/escalation
- Serves as a subject matter expert in payer appeals resolution process
- Experience working in grievances and appeals, claims, or customer service, familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, Anthem internal business processes, and internal local technology
- Managed care experience within a managed care organization, physician, IPA or billing environment with experience in revenue cycle management and managed care contracting related fields
- Familiarity with Medicare ODAG/CDAG regulations and medical terminology
- Legal, Government, & Jurisprudence
- Understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background
8
Skills For Appeals Analyst Resume
- Claim processing/adjudication experience including demonstrated success in utilizing problem solving and communication skills to diagnose problems and resolve complicated issues
- Experience in managed care contract, reconciling patient accounts and balancing payments transactions against contract rates and terms
- Knowledge of third-party payer, Medicare/Medicaid guidelines
- Perform root cause analysis, problem solve, and prepare action plans for improvement initiatives
- Basic recognition of CPT, HCPCS and ICD 9/10 coding. Certified Professional Biller within 6 months of hire Ability to manage projects and handle multiple priorities under stressful situations
- Quickly makes sense of, combines and organizes information
- Consistently maintains a professional and approachable demeanor
- Work under pressure and meet stringent deadlines in a fast~paced environment
9
Skills For Denials / Appeals Analyst Resume
- Successfully alternates between two or more activities or sources of information
- Accepts responsibility and maintains high level of accountability
- 2) Resolving issues related to appeals and audits under FEMA’s Public Assistance Program through research, analyses, and development of responses to grant related matters in dispute
- Identifies and handles appeals that by statute require a settlement consultation, and leads or participates in settlement negotiations
- Provides background to, strategizes with, and reviews and comments on draft pleadings prepared by the Office of the Solicitor and the Department of Justice
- Advises on statutes, regulations, case law, guidance documents, policies, and practices governing or affecting oil, gas, coal, solid mineral, and geothermal production reporting, royalty reporting, and royalty payment
- Responsible for Director and Assistant Secretary decisions on, and other dispositions of, appeals filed by the oil, gas, coal, solid minerals, and geothermal industries under Title 30 of the Code of Federal Regulations, Part 1290
- Manage assigned caseload of Short Term Disability appeals
- Administer and expertly apply contractual provisions
10
Skills For Grievance / Appeals Analyst Resume
- Identify opportunities for improved claim management across the organization
- Work independently to manage difficult interactions
- Appears before the Member Appeals Committee Benefit Issues & Complaints (MACBIC) at routinely scheduled hearings to present cases
- At hearings, responsible for the comprehensive explanation of denials, the scope of coverage, and how the case was handled
- Responsible for contacting all areas of the Company which handled the case in to facilitate fact gathering and to gain a thorough understanding of the benefit contract
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