Senior Appeals Specialist - Workers' Compensation

Senior Appeals Specialist – Workers’ Compensation

As a Senior Appeals Specialist – Workers’ Compensation, you will play a critical role in resolving post-payment disputes related to Workers’ Compensation bills. This includes conducting provider outreach, negotiating disputed charges, and ensuring compliance with state-specific regulations. Your work will directly support our cost containment efforts and ensure appropriate bill reimbursement for our clients.

Primary Responsibilities

• Manage a caseload of post-payment Workers’ Compensation bills, including those related to state disputes and usual and customary rate (UCR) disputes.
• Assigned high priority clients in managing all items related to the service with Reliant
• Conduct proactive outreach to medical providers to explain payment methodologies, resolve disputes, and negotiate reductions on appealed or outlier bills.
• Communicate effectively and professionally with clients to coordinate and investigate information as it relates to the case/appeal.
• Educate providers on Workers’ Compensation billing and reimbursement policies and regulatory requirements.
• Document all provider communications thoroughly, including contact information, bill details, proposed and counter-offered payment rates, and final resolution in claim platform.
• Adhere to state-specific compliance standards and confidentiality requirements, including HIPAA.
• Maintain productivity and quality standards, ensuring timely resolution of bills in accordance with state timelines and internal service level agreements.
• Follow client-specific protocols and internal Reliant procedures, including scripting and documentation guidelines.
• Stay current on Workers’ Compensation regulatory changes, fee schedules, and payment policies across multiple states.
• Support special projects and perform additional duties as assigned.
• Responsible for training team members both upon hire and for existing team members.
• Responsible for overseeing all DWD handling and state dispute referrals to attorneys.
• First line for all support with questions from other team members.
• Backup for other team members and/or senior leadership
• Works with appeals intake specialist to ensure process documents remain current
• Responsible for identifying opportunities for enhancement either through automation or process changes that increase efficiency for the team
• Responsible for team goals and ensuring that individuals meet their personal goals

Qualifications

• 5 years of relevant experience in Workers’ Compensation bills, medical billing, medical coding, or insurance negotiations.
• Strong understanding of Workers’ Compensation reimbursement methodologies, state regulations, and provider billing practices.
• Experience negotiating medical bill payments or adjustments with providers.
• Ability to collaborate with a variety of individuals both internally and externally.
• Familiarity with claims processing systems and provider communications.
• Excellent communication, negotiation, and organizational skills.
• Requires communication proficiency, discretion, ethical conduct, decision making and technical skills