Job Description

Vālenz® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.  

 

About Our Opportunity 

As an Appeals Analyst, you will resolve of out-of-network, RBP, and related appeals. This encompasses not only negotiating reimbursement rates but also evaluating, denying, or settling appeals. You'll comply with industry guidelines and contracts, while liaising with our clients. Your contribution will be pivotal in analyzing appeals, conversing with providers, and determining the fairness and justification of claim counteroffers. 

 

Key Responsibilities:

• Receive, review, and address appeals from providers, ensuring that all appeals are processed in accordance with ERISA, plan guidelines, and other applicable regulations. 

• Reviews and evaluates provider counteroffers on claims, analyzing their legitimacy to ensure they're justified, equitable, and aligned with the best possible outcome for all parties. 

• Engage in negotiations with providers to achieve optimal results for clients, sometimes necessitating a direct denial or alternative negotiations. 

• Calculate and propose initial settlement offers based on claim history, other pricing tools, and relevant data. 

• Complete agreement templates detailing negotiated terms and forwards them to the provider for review. 

• Follow up on outstanding agreements to ensure timely closure. 

• Records and documents finalized agreements for future reference and compliance. 

• Ensures that claims are priced accurately, reflecting the terms stipulated in the finalized agreement. 

• Engages in regular communication with clients to update them on appeal statuses, outcomes, and other pertinent information. 

• Utilizes support software, such as Zendesk, ensuring adherence to all SLAs and ensuring efficiency and accuracy in communication. 

• Maintains strict compliance with company policies, procedures, and relevant regulations. 

Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties. 

 
What You’ll Bring to the Team: 

• 2+ years in analyzing, denying, or settling out-of-network appeals. 

• Proficient in CPT-4, HCPCS, Revenue, DRG, and ICD-10 coding for accurate claim reviews. 

• Knowledge of the No Surprise Act, ERISA guidelines, and related legislations. 

• Proven negotiation skills with providers for claim adjustments and counteroffers. 

• Strong analytical ability for evaluating claims using pricing tools and past data. 

A plus if you have: 

• Experience with international plans 

• Experience in self-funded insurance 

Where You’ll Work 

This is a remote role. 

Why You Will Love Working Here

We offer employee perks that go beyond standard benefits and compensation packages – see below!

At Valenz, our team is committed to delivering on our promise to  engage early and often for smarter, better, faster healthcare . We want everyone engaged within our ecosystem to be strong, vigorous, and healthy. You’ll find limitless growth opportunities as we grow together. If you're ready to utilize your skills and passion to make a significant impact in the healthcare self-funded space, Valenz might be the perfect place for you!

Perks and Benefits

• Generously subsidized company-sponsored Medical, Dental, and Vision insurance.
• Spending account options: HSA, FSA, and DCFSA
• 401K with company match and immediate vesting.
• Flexible working environment.
• Generous Paid Time Off to include Vacation, Sick, and Paid Holidays.
• Paid maternity and paternity leave.
• Community giveback opportunities, including paid time off for philanthropic endeavors.

At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.

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