Appeals Review Specialist

Imagine360 • ,

7d • Remote

About The Position

Imagine360 is seeking an Appeals Review Specialist to review provider claims for possible errors and help protect plan assets. The role maintains a comprehensive understanding of the plan documents within its scope of responsibility and is 100% remote.

The specialist reviews claims against medical records, examines claim edits for fraud and abuse, and escalates claims to the Utilization Management Vendor when appropriate. The role also researches and responds to member and provider inquiries, complaints, and objections to denied coverage; explains denials; and communicates accurately and promptly in writing and/or by phone.

The specialist supports customer service for internal and external customers, trains claims employees to improve the quality of reviews and appeals, contributes to quality assurance and process improvement, and maintains regulatory compliance. Other duties may be assigned by the supervisor.

Requirements

• High school diploma or equivalent.
• At least two years of experience in healthcare claims examining or related work.
• Working knowledge of computers and software, including Microsoft Office products.
• Proficient 10-key and typing skills.
• Self-motivation, organizational skills, and problem-solving skills.
• Strong written and oral communication skills, with attention to detail and accuracy.
• Ability to remain neutral and maintain confidentiality.

Responsibilities

• Review claims and claim edits for possible errors and accuracy against medical records.
• Review claims edits for fraud and abuse.
• Escalate claims to the Utilization Management Vendor when appropriate.
• Research and respond in writing to member and provider questions, complaints, and objections to denied coverage.
• Provide explanations of denials and respond accurately and promptly to inquiries in writing and/or by phone.
• Train claims employees to improve the quality of reviews and appeals.
• Demonstrate core values in customer service delivery and provide timely, thorough follow-up with internal and external customers.
• Send letters to providers and members explaining denials.
• Escalate difficult issues appropriately through the chain of command.
• Participate in assigned committees, work groups, and process improvement teams to improve quality and customer satisfaction.
• Identify and alert an appropriate supervisor to trends outside quality parameters.
• Monitor personal quality and develop and execute plans to meet established goals.
• Provide ongoing feedback to optimize quality performance.
• Collaborate across departments to improve or streamline procedures and develop or improve internal processes.
• Maintain regulatory compliance standards.
• Perform other duties or follow other instructions requested by the supervisor.

Benefits

• Multiple health plan options.
• Company-paid employee premiums for disability and life insurance.
• Parental leave policy.
• 20 days of PTO to start and 10 paid holidays.
• Tuition reimbursement.
• 401(k) company contribution.
• Professional development initiatives and continuous learning opportunities.
• Opportunities to participate in and support the company's diversity and inclusion initiatives.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED