Appeals and Grievances Specialist

Network Health WI•Menasha, WI

4d•Remote

About The Position

Network Health is seeking an Appeals and Grievance Specialist I to review member appeals and grievances, investigate and summarize findings, compile supporting documentation, and prepare summaries of determinations. The role supports a collaborative, innovative team focused on providing members with world-class service through the appeals process. Candidates must reside in Wisconsin. The position is eligible to be performed from a home office with reliable internet, with occasional travel to the corporate offices in Menasha or Brookfield, including on the first day. The schedule is 1.0 FTE, 40 hours per week, Monday through Friday, 8 a.m. to 5 p.m.

Requirements

At least two years of experience working for a health insurance carrier or in a similar environment.
Excellent communication skills and the ability to interpret insurance plans and regulations.
Strong Microsoft Word and Excel skills.
Ability to research regulations.
High school diploma or equivalent.

Nice To Haves

Experience in appeals and grievances, customer service, claims, utilization management, or compliance.
Experience working with state and federal regulations, such as Medicare, ERISA, or Office of the Commissioner of Insurance regulations.
Associate degree.

Responsibilities

Review assigned appeals and grievances and determine the supporting documentation needed to address each issue.
Compile documentation for the appeal process and resolve information discrepancies with internal departments or providers as needed.
Communicate with members about appeal status, obtain missing information through appropriate outreach, and explain the appeals and grievances process.
Investigate and summarize findings, present cases, and obtain resolutions for assigned benefit-related cases within legally required timeframes and applicable regulations.
Document investigations and resolutions in the Appeals and Grievance database, including dates and times of required verbal and written notifications.
Collaborate with the legal department on hearing requests before an Administrative Law Judge, prepare and submit required documentation, and provide testimony by phone or in person as necessary.
Prepare letters or written summaries for members, providers, and third parties explaining benefit determinations and their rationale in accordance with benefit documents and applicable regulations.
Demonstrate behavior aligned with Network Health's philosophy, mission, values, and vision.
Perform other duties and responsibilities as assigned.