Appeals Specialist

Appeal Submission

• Review denied claims and determine appropriate appeal strategy based on payer guidelines.
• Prepare and submit appeal letters with supporting documentation (payer forms, medical records, prior authorization details, clinical justification).
• Ensure appeals are submitted via the payers’ preferred format (portal, fax, mail) within payer-specific timelines to avoid missed opportunities.

Post-Submission Follow-Up

• Track appeal status and maintain accurate records in the billing system.
• Contact insurance companies to confirm receipt and progress of appeals.
• Escalate unresolved appeals or complex cases to management as needed.

Research & Compliance

• Stay current on payer policies and appeal requirements for molecular and genetic testing.
• Ensure all appeal activities comply with HIPAA and regulatory standards.
• Identify trends in denials and collaborate with reimbursement teams to reduce future occurrences.

Collaboration & Communication

• Work closely with prior authorization, billing, and payer relations teams to gather necessary documentation.
• Communicate with providers when additional clinical information is required for successful appeal.