Appeals Specialist II

Health Care Service Corporation•National, NV

4d•$19 - $34•Remote

About The Position

Under supervision, the Appeals Specialist II processes and adjudicates complex non-utilization management appeals in accordance with applicable federal, state, and NCQA requirements and regulations. The role responds by phone, in person, or in writing to inquiries involving members’ appeal requests and may train and mentor less experienced Appeals Specialists. This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii. Compensation varies based on job-related skills, education, knowledge, experience, and location. The role aligns with an annual incentive bonus plan subject to its terms and conditions.

Requirements

High school degree or GED.
Three years of experience in a customer service role or in a health insurance or medical environment.
Knowledge of medical terminology, including coding.
Ability to analyze and assist customers using knowledge of federal, state, and NCQA guidelines.
Ability to organize tasks and accommodate a large volume of reference materials.
Ability to understand fine details of customer complaint issues.
Verbal and written communication skills.

Nice To Haves

Claims experience.
Two years of experience processing claims and using a claims payment system.
Bilingual English/Spanish.

Responsibilities

Process and adjudicate complex non-utilization management appeals according to applicable federal, state, and NCQA requirements and regulations.
Respond by phone, in person, or in writing to inquiries involving members’ appeal requests.
May train and mentor less experienced Appeals Specialists.