About Zealie LLC

Zealie is a fast-growing Medical Billing company specializing in the Behavioral Healthcare industry. Our clients are substance use disorder treatment, addiction recovery, and mental health treatment centers that are saving lives on a daily basis. Our state of the art proprietary technology provides data analytics and revenue prediction tools to our clients to help them make strategic business decisions to grow their business. We are committed to delivering exceptional products and services to our clients and believe that our team plays a crucial role in achieving this mission. We are seeking motivated individuals with a desire to be a part of a winning team.

The Appeals Specialist manages assigned insurance claim appeals from initial review through submission, documentation, and follow-up. The role involves analyzing denial reasons, reviewing medical records and supporting documentation, preparing appeal submissions, coordinating with facilities and internal teams, and tracking claim outcomes. The specialist is expected to meet established productivity, quality, and turnaround-time requirements while following payer guidelines, internal procedures, and applicable deadlines.

Essential Duties and Responsibilities

● Review denied claims, payer responses, and claim history to identify denial reasons and determine the appropriate next steps.

● Review medical records and supporting documentation to identify information relevant to the denial and the appeal.

● Prepare accurate, complete, and appropriately supported appeal letters and submission packets in accordance with payer requirements.

● Submit first-level and second-level appeals through payer portals, electronic systems, fax, or mail, as applicable.

● Coordinate ERO/IRO or other applicable review processes in accordance with established workflows.

● Track appeal submissions, filing deadlines, claim statuses, and follow-up dates in the designated systems.

● Contact payers to obtain claim or appeal status, document responses, and take the next required action.

● Coordinate with facilities and internal teams to obtain missing medical records, authorization forms, and other supporting documentation.

● Identify missing information, discrepancies, recurring denial patterns, and workflow barriers; escalate unresolved issues to the Team Lead or appropriate stakeholder.

● Prioritize urgent, aging, and deadline-sensitive claims and work assigned inventory in accordance with team procedures. ● Maintain complete, factual, and timely notes and ensure claim records accurately reflect actions taken and next steps.

● Follow department SOPs, payer-specific requirements, privacy and confidentiality standards, and applicable compliance requirements.

● Meet established productivity, quality, timeliness, and documentation expectations and participate in coaching or process-improvement activities as needed.

Required Qualifications:

Bachelor's Degree preferred. Relevant education or training in healthcare administration, medical billing, health information management, or a related area may be considered.

Experience:

2 years of prior experience in claims follow-up, insurance appeals, medical records, revenue cycle operations, medical billing, or a related healthcare administrative function is preferred.

Systems:

Ability to learn and use claim-management platforms, payer portals, electronic documentation systems, and standard office applications.

Knowledge, Skills, and Competencies

● Analytical thinking and the ability to interpret denial reasons and determine appropriate follow-up actions.

● Accuracy in reviewing medical records, preparing appeal documentation, and entering claim notes.

● Working knowledge of appeal workflows, payer submission methods, filing deadlines, and documentation requirements. ● Written and verbal communication skills for clear coordination with payers, facilities, and internal teams.

● Organization, prioritization, and time management when handling a high volume of claims.

● Ownership of assigned work, reliable follow-through, sound judgment, and timely escalation of barriers.

● Ability to work independently and collaboratively while adapting to changing priorities. Performance Measures

● Productivity against department-approved targets.

● Quality and accuracy of appeal submissions, notes, and claim updates.

● Timely action on appeals and follow-ups within applicable deadlines and established turnaround times.

● Completeness and accuracy of documentation in designated systems.

● Effective management of assigned inventory, including aging claims and pending follow-ups.

● Adherence to SOPs, payer requirements, confidentiality expectations, and compliance standards.