Appeals Specialist, Appeals RnD

About the Role

PrimEra Medical Technologies is seeking Appeals Specialists to join their Appeals RnD team. This role involves analyzing patient accounts, identifying appeal opportunities, and researching industry updates, legal aspects, and strategic enhancements in the appeals process. The position is at the intersection of operations, process innovation, and healthcare regulatory strategy.

Key Responsibilities

• Conduct in-depth analysis of patient accounts to determine eligibility for technical appeals.
• Identify potential appeal opportunities based on payer guidelines, claim denials, and compliance regulations.
• Develop and implement appeal strategies to maximize revenue recovery and ensure compliance with regulatory policies.
• Work closely with internal teams to streamline workflows and improve efficiency in the appeals process.
• Stay updated on healthcare regulations, payer policy changes, and legal precedents affecting technical appeals.
• Research emerging trends in Revenue Cycle Management (RCM), Accounts Receivable (AR), and payer adjudication processes to enhance appeal success rates.
• Collaborate with cross-functional teams to develop innovative solutions for technical appeals.
• Assist in crafting operational strategies to enhance the effectiveness of the appeals process.
• Identify and propose technology-driven improvements that support scalability and efficiency in appeals management.
• Work closely with internal teams such as operations, legal, compliance, and other revenue cycle teams to align appeal strategies with business objectives.
• Support leadership in data-driven decision-making, reporting key metrics, and providing insights for process improvements.
• Utilize coordination skills to manage workflow optimization projects, track milestones, and contribute to organizational process enhancement initiatives.

Requirements & Tech Stack

• Proficiency in MS Office: Excel, Word, and PowerPoint.
• Strong documentation and presentation abilities.

Qualifications

• Graduate degree in BDS/MBBS/PharmD, with an MBA/MPH/MHA.
• Strong ability in analytical thinking and research acumen to analyze data, recognize trends, and identify strategic appeal opportunities.
• Innovative problem-solving skills to develop creative appeal strategies and process improvements.
• Basic to advanced understanding of Accounts Receivable (AR) and Revenue Cycle Management (RCM) concepts, payer policies, and reimbursement methodologies.
• Familiarity with healthcare regulations, payer guidelines, and appeal adjudication frameworks is a plus.
• Ability to support project management tasks, coordinate workflow optimization, and assist in strategy planning efforts.
• Ability to extract insights from denial trends, financial reports, and operational data to drive informed decision-making.
• Excellent ability to communicate findings, coordinate with internal teams, and present recommendations effectively.