Appeals Examiner #00064
About The Position
The Department of Human Resource Management, Office of Health Benefits is seeking a qualified individual to fill the position of Appeals Examiner. This position will be responsible for conducting comprehensive investigations of claim and administrative appeals to ensure fairness, accuracy, and equitable outcomes for appellants. This role includes evaluating clinical appeals and coordinating reviews with contracted independent review organizations. In addition, the position will oversee the intake and resolution of member complaints and manages system transaction audits to ensure adherence to program policies. Also, this position will be responsible for providing guidance to state agency Benefits Administrators, employees, and retirees on relevant policies and procedures, and collaborates with OHB staff on projects and vendor compliance activities.
Requirements
- Comprehensive knowledge of health benefits policies and practices, including program administration and compliance requirements.
- Working knowledge of regulations and procedures governing appeals, with the ability to interpret and apply them effectively.
- Strong analytical skills to evaluate complex information and apply policies and regulations accurately.
- Proficiency in computer applications to prepare correspondence and reports.
- Excellent written and verbal communication skills, with the ability to convey information clearly and professionally.
- Strong organizational and time management abilities, including the capacity to set priorities, work independently, and meet objectives with minimal supervision.
- Commitment to exceptional customer service, ensuring responsiveness and professionalism in all interactions.
Nice To Haves
- Experience with medical claims is preferred.
- Background in utilization review is highly desirable.
- Education, certification, or hands-on experience in health benefits administration and/or claims handling is preferred.
Responsibilities
- Conducting comprehensive investigations of claim and administrative appeals to ensure fairness, accuracy, and equitable outcomes for appellants.
- Evaluating clinical appeals and coordinating reviews with contracted independent review organizations.
- Overseeing the intake and resolution of member complaints.
- Managing system transaction audits to ensure adherence to program policies.
- Providing guidance to state agency Benefits Administrators, employees, and retirees on relevant policies and procedures.
- Collaborating with OHB staff on projects and vendor compliance activities.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
