Appeals Specialist

1 month ago
Job ID
2017-5059
US
Category
Commercial Operations

Overview

The Appeals Specialist works directly within GHI systems and extensions to address patients, prescribing physicians, sales force and payers to increase overturned medical necessity or other clinical claim denials to gain maximum coverage of Genomic Health (GHI) products. He/She will handle a large case load, which are generally unique and complex, using comprehensive clinical and resource knowledge to interpret medical records and physician notes, and compose clearly articulated letters of appeal. In addition, he/she will work closely with the Medical Affairs and Managed Care teams to develop targeted appeals strategies.

Responsibilities

  • Identify opportunities and pursue approvals, overturn denials, seek alternative methods of coverage, and establish precedence with key payers.
  • Demonstrate clinical expertise related to oncology care; arrange and prepare physicians for peer review; write draft letters of medical necessity for prescribing physician
  • Demonstrate cost effectiveness for payers
  • Interpret medical policy guidelines
  • Use historical approvals with same/similar payers
  • Use FDA approval letters and compare Medicare policy guidelines with the patient’s indications
  • Use Hayes and Blue Cross Blue Shield (BCBS) Technology Assessment Committee report and indicating higher ranking
  • Develop and follow a process for cases that require state insurance commissioner review
  • Engage patient advocacy groups to increase awareness
  • Implement any other creative and appropriate methods and leverage resources to gain a favorable outcome
  • Create a method to track all cases in appeal for performance measurement and outcomes purposes
  • Update intake staff of payer successes and provide coaching to overcome payer objections to coverage
  • Performs other duties as assigned

Qualifications

To perform this job successfully, the ideal candidate is capable of performing each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.

 

Educations and/or Experience:

  • Bachelor’s Degree in Nursing with a Registered Nurse designation preferred, but not required
  • 8-12 years experience as a hospital or payer based case manager or discharge planner
  • Excellent clinical skills related to oncology case management.
  • Persuasive negotiation and time management skills along with a strong knowledge of all payer types, to include Medicare, Medicaid, and third party commercial insurance companies.
  • Proficiency in MS Office Suite.

Language Skills: Ability to read and comprehend instructions, correspondence, and memos. Ability to write correspondence and be persuasive. Ability to effectively present information in one-on-one and small group situations to customers, clients, payors and other employees of the organization.

Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Travel, Physical/Mental Demands and Work Environment

CORPORATE OFFICE JOBS:  TRAVEL, PHYSICAL/MENTAL DEMANDS AND WORK ENVIRONMENT:
 
 
- Use of computer, and or telephone for long periods of time may be necessary.
- Travel Requirements: <25%
- Considerable periods of time may be spent concentrating and or analyzing data
- Considerable periods of time may be spent communicating verbally and in various written forms including presentation material and email with other people
- At times, stress may be experienced.   
- Standing or sitting for long periods of time may be necessary
- Some lifting (greater than 25 pounds) may be necessary; Facilities, Materials and Engineering employees occasionally must lift at least 50-75 pounds.
- May be exposed to hazardous materials, tissue specimens and instruments with moving parts, lasers, heating and freezing elements, and high speed centrifugation (GENERALLY LABORATORY & CUSTOMER SERVICE  EMPLOYEES ONLY)
 
SALES AND OTHER JOB THAT REQUIRE CONSIDERABLE TRAVEL:  TRAVEL, PHYSICAL DEMANDS AND WORK ENVIRONMENT: 
 
 
Edit, add, or delete below as appropriate and access (free) www.onetonline.orgas a resource for physical/mental requirements:
 
- Travel Requirements: 
[Select One: No Travel, 10% Travel, 30% Travel, 50% Travel, More than 50% Travel]
[Note if the following is required: suitable vehicle, valid automobile insurance, valid driver’s license, good standing DMV record]
[Note territory or geographic area for travel]
- Standing or sitting for long periods of time may be necessary
- Some lifting (greater than 25 pounds) may be necessary;
- Use of computer, and or telephone for long periods of time may be necessary.
- A considerable amount of time can be spent listening, and communicating including face to face discussions clients and other people
- Some time may be spent communicating in various written forms including presentation material and email with other people
- At times, stress may be experienced
- Considerable amount of work performed within a home office
 
 
LAB/SERVICE PROCESS ENGINEERING JOBS:  TRAVEL, PHYSICAL/MENTAL DEMANDS AND WORK ENVIRONMENT
 
Edit, add or delete below as appropriate and access (free) www.onetonline.orgas a resource for physical/mental requirements:
 
- Standing or sitting for long periods of time may be necessary
- Some lifting (greater than 25 pounds) may be necessary.
- Considerable amount of time using various types of laboratory equipment including microscopes, microtomes, blades, strainers, pipettes
- May perform repetitious actions using lab tools
- Some time spent using near vision to view samples at close range
- Use of various chemicals may be used to perform duties
- At times, stress may be experienced
- Use of computer and some time may be spent concentrating, reading, or analyzing data, or applying scientific rules
- May be exposed to hazardous materials, tissue specimens and instruments with moving parts, lasers, heating and freezing elements, and high speed centrifugation (GENERALLY LABORATORY & CUSTOMER SERVICE  EMPLOYEES ONLY)

Company Profile

Genomic Health is a global provider of genomic-based diagnostic tests that address the overtreatment of cancer, one of the greatest issues in healthcare today. Our goal is to improve the lives of people with cancer by providing personalized, biological information that helps them get the right treatment at the right time, and to avoid unnecessary treatments and their side effects. In this way, our work is truly life, changing.

 

  • Our Oncotype IQ Genomic Intelligence Platform is a portfolio of diagnostic tests that help physicians and patients answer specific and critical treatment questions throughout the cancer journey
  • We currently offer Oncotype tests addressing breast, colon, prostate and lung cancers and hundreds of thousands of patients from over 90 countries have benefited from our tests.
  • The Oncotype DX breast cancer test is considered standard of care in the US and is included in all major international clinical guidelines for breast cancer treatment.
  • We are expanding our portfolio of tests to include additional liquid- and tissue-based tests through clinical research and internal product development as well as strategic partnerships.

 

Join the Genomic Health Team, and have the unique opportunity to make a difference in the lives of patients with cancer, while developing your career potential.  We embrace our unique culture characterized by our Core Values of Community, Truth Seeking, Being Ahead of the Curve and Winning to be the best in the world at what we do. We maintain competitive total rewards programs designed to satisfy our employees’ work life and personal life needs. 

 

All qualified applicants will receive consideration for employment without regard to race, sex, gender identity, color, religion, national origin, protected veteran status, or on the basis of disability.

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