Appeals Specialist

Key Responsibilities Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals. The end-to-end process requires the Specialist to independently: Research issues Reference and understand HFs internal health plans policies and procedures to frame decisions Interpret regulations Resolve cases and make critical decisions Edit and finalize resolution letters Manage all duties within regulatory timeframes Communicate effectively to hand-off or pick-up work from colleagues Work within a framework that measures productivity and quality for each Specialist against expectations Work independently exercising judgment starting the case development with the respective internal and external entities in the timeframe prescribed in the Job Aid and/or regulatory timeframes. Prepare and submit well documented appeals in accordance with payer guidelines and within timely filing limits Identify patterns or trends in denials and provide feedback for leadership for process improvement. Remain up to date on payer polices, industry regulations and coding updates to ensure compliance and maximize reimbursement Additional duties as assigned Minimum Qualification HS Diploma or GED from an accredited institution Minimum of two (2) years of work experience in Managed Care Health Insurance Plan Experience with appeals for Medicare, Medicaid, Dual enrollment and commercial Plans end to end. Claims processing experience with coding criteria is preferred. This includes the auto forwarding of upheld cases to the respective regulatory independent reviewer for denied cases. Preferred Qualifications Bachelors degree from an accredited institution or relevant work experience Demonstrated critical thinking and decision-making competencies Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.

Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.