Payer Compliance/Appeals SME

Appeal Subject Matter Expert (SME)

**This is a Remote Position**

About Zealie

Zealie is a fast-growing Medical Billing Services company specializing in the Behavioral Healthcare industry. Our clients include substance use disorder treatment, addiction recovery, and mental health treatment centers that save lives every day. Our proprietary technology provides data analytics and revenue prediction tools that empower clients to make strategic business decisions and grow their organizations.

We are committed to delivering exceptional products and services, and our Medical Records team plays a critical role in achieving this mission. We are seeking a Subject Matter Expert (SME) in Medical Records to provide advanced expertise, training, and strategic guidance that ensures compliance, accuracy, and payer alignment across the department.

Job Summary

The Appeal Subject Matter Expert (SME) provides specialized expertise in claims appeals and denial management, ensuring all appeals are accurate, compliant, and timely. This role acts as the primary resource for complex appeal cases and payer-related escalations, guiding the team in interpreting payer requirements, reviewing documentation, and ensuring that appeals meet medical necessity and compliance standards.

The SME supports and mentors team members, delivers training on appeal workflows and payer guidelines, and partners with leadership to enhance efficiency, reduce denial rates, and improve overall reimbursement outcomes. The role requires strong analytical skills, in-depth knowledge of payer policies, and the ability to communicate effectively with both internal teams and external partners.

Responsibilities and Duties
Expert Guidance and Support

• Serve as the primary escalation point for complex or high-priority appeals.
• Provide advanced expertise on payer requirements, clinical criteria, and denial management best practices.
• Analyze denial trends to identify systemic issues and recommend corrective actions.
• Support team leads in implementing appeal strategies that improve overturn rates and reduce aging denials.

Appeal Management Expertise

• Ensure timely and accurate submission of appeals according to payer-specific timelines and protocols.
• Maintain expert knowledge of payer portals, appeal submission formats, and documentation requirements.
• Collaborate with billing, coding, and clinical documentation teams to gather and validate necessary information.
• Uphold confidentiality and compliance with HIPAA and organizational data standards.
• Support automation and process optimization initiatives related to denial tracking and appeal workflows.

Compliance and Documentation

• Ensure all appeals adhere to legal, regulatory, and payer-specific requirements.
• Monitor payer updates and policy changes; communicate relevant updates to the appeals team.
• Assist in preparing documentation for internal audits, payer reviews, and external compliance assessments.
• Maintain detailed records of appeal outcomes, payer correspondence, and corrective actions.

Training and Development

• Design and deliver training sessions for Appeal Specialists on denial management, documentation standards, and payer appeal processes.
• Develop and maintain knowledge base materials, templates, and reference guides for consistent appeal handling.
• Promote continuous learning and cross-department collaboration to strengthen team expertise.

Collaboration and Communication

• Partner with clinical, billing, and quality teams to ensure appeals align with payer expectations and support medical necessity.
• Communicate appeal outcomes and trends to management and other departments.
• Provide insights on denial root causes to help shape process improvements and policy updates.
• Participate in cross-functional meetings to represent the appeals team's perspective on documentation and compliance.

Duties

• Conduct daily reviews of medical record discrepancies and AOR (Authorization of Representation) requests; contact facilities to correct deficiencies.
• Assist in resolving interdepartmental issues related to claim denials or documentation gaps.
• Track performance metrics such as overturn rate, timeliness, and appeal accuracy.
• Maintain organized documentation of appeal findings, training sessions, and process recommendations.
• Perform additional duties as requested by leadership, supporting continuous improvement and operational excellence.

Qualifications

• Minimum 3–5 years of experience in claims appeals, denial management, or related revenue cycle roles.
• Deep understanding of payer guidelines, appeal procedures, and documentation standards.
• Strong written and verbal communication skills with the ability to interpret complex payer feedback.
• Proficient in EHR systems, payer portals, and Microsoft Office Suite.
• Demonstrated ability to mentor peers and contribute to process improvement initiatives.

Skills:

• Recognized expertise in health information management and payer requirements.
• Strong analytical skills for reviewing medical records, AR, appeals and identifying compliance or documentation gaps.
• Excellent communication skills, capable of translating complex requirements into clear guidance.
• Ability to develop training and mentoring programs that elevate team expertise.
• Deep knowledge of HIPAA regulations and behavioral health care levels (DTX, RTC, PHP, IOP, OP).
• Experience with regulatory compliance appeals including ERO/IRO appeals

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