Appeals Specialist I

Utah Retirement Systems•Salt Lake City, UT

About The Position

The Appeals Specialist I researches and processes member and provider appeals involving medical, dental, FSA, and enrollment matters. The role compiles documentation for review by the PEHP Executive Review Committee and Provider Dispute Review Committee, and helps ensure appeals are handled in accordance with PEHP Master and Corporate Policy, state and federal regulations, and provider contracts. The position also supports policy and benefit-document maintenance, claims payment policies, reporting, and imaging tasks. The successful candidate has strong writing and communication skills, conflict-management experience, analytical ability, and the capacity to work effectively both independently and as part of a team. PEHP Health & Benefits is a division of Utah Retirement Systems serving Utah public employees with self-funded medical, dental, life, and long-term disability insurance plans. The organization describes its mission as creating customer value, excelling in the market, and improving healthcare. Most jobs offer remote work for 9 out of every 10 workdays; the listed work environment for this position is a typical climate-controlled office setting.

Requirements

High school diploma and one year of progressively responsible experience performing a variety of technical and administrative duties, or an equivalent combination of education and experience.
Working knowledge of Microsoft Office Suite.
Working knowledge of healthcare coding and information systems.
Working knowledge of office management systems for alphanumeric record keeping.
Working knowledge of basic mathematics and calculations involving figures such as discounts and percentages.
Basic knowledge of research techniques and Master Policy and procedure development processes.
Basic knowledge of medical, dental, pharmacy, mental health, and Medicare Supplement claims, adjudication policies, procedures, and processes.
Basic knowledge of HIPAA privacy policies and PEHP's internal privacy policy.
Basic knowledge of benefits review processes and procedures.
Excellent written and verbal communication skills, including reading and interpreting plan policies, preparing routine and technical correspondence, presenting information, answering questions, telephone etiquette, and basic public relations.
Ability to problem-solve, analyze information, and draft technical reports and documents.
Ability to maintain effective working relationships with professionals, department heads, coworkers, and the public.
Ability to follow written and verbal instructions, prioritize work, meet deadlines, work independently and in a team, multitask, follow through on assignments, and manage workload-related stress and time deadlines.
Demonstrate judgment, high integrity, and personal values consistent with the values of URS.

Nice To Haves

PEHP experience is preferred.

Responsibilities

Research requests from providers for review of resolvable claims and compile information for member appeals requesting Executive Review.
Provide necessary documents and information to the Appeals and Policy Manager for review; prepare and distribute appeal information packets to Executive Review Committee members before scheduled meetings.
Maintain current data on appeals and resolvable claims.
Meet with members to coordinate review of payment documents and records related to appealed claims, and provide copies upon request.
Ensure compliance with state and federal regulations and provider contracts throughout the appeals process.
Ensure denied claims approved on appeal are paid promptly and correctly according to Executive Review Committee directives.
Write correspondence to members and providers about appeal outcomes and benefit determinations, document committee decisions, and record appeal approvals or denials in member histories and the Case Data Management log.
Maintain files and documentation for the development and updating of the Master Policy and related documents, submit proposed changes to the Appeals and Policy Manager, record approvals, ensure approved changes are made, and communicate changes to affected employees.
Help research correct coding for medical, dental, and pharmacy payment policies and procedures created by Clinical Management, and provide updated information for claims payment editing systems.
Maintain reports used to track departmental functions and productivity.
Perform imaging tasks.
Receive referrals from adjusters, customer service, providers, and insured members through claims-history screening and system automation; work with providers, vendors, and members to obtain relevant records and information.
Maintain strict confidentiality.
Perform other duties as required.