Appeals Specialist

UHS•Reno, NV

96d

About The Position

Under the direction of the Manager of Operations, the Appeals Specialist is responsible for ensuring the appropriate review, research, processing and responding to written member and provider complaints, appeals, and grievances. This position is required to apply analytical and critical thinking when reviewing contract language, benefits and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of Insurance in accordance with state and federal regulations, company policies and NCQA/HEDIS standards. Compile, analyze and maintain statistical data and trends to maintain the highest level of standards. Additional responsibilities include assuming responsibility of the Department in the absence of the Department Manager.

Requirements

Associate degree or equivalent work experience.
Course work to include English, Grammar and Composition, and Mathematics.
Two years in a managed care industry preferred, two of which are in a customer service position with proven ability in effectively identifying and resolving customer issues.
Ability to effectively communicate in English, both verbally and in writing.
Understanding of claims payment and utilization management process.
Excellent organizational, written, and oral, communication, and human relation skills are essential.
Letter writing proficiency with an emphasis on quality and accuracy is most important.
Ability to work independently and willingly offers assistance.
Must demonstrate knowledge of those State and Federal laws and regulations, company policies and procedures, and NCQA/HEDIS standards applicable to complaints and appeals process.
Knowledge of CPT/ICD-10 coding with an understanding of medical terminology.
Valid Nevada Driver’s license and dependable transportation required.
Excellent working relationship with Medical Management staff, Medical Director and Claims Managers as it relates to Member or Provider Appeals/Correspondence.
Ability to satisfactorily complete a battery of job-related tests.

Nice To Haves

Valid Nevada State Health Insurance license is preferred.

Responsibilities

Ensuring the appropriate review, research, processing and responding to written member and provider complaints, appeals, and grievances.
Applying analytical and critical thinking when reviewing contract language, benefits and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of Insurance in accordance with state and federal regulations, company policies and NCQA/HEDIS standards.
Compile, analyze and maintain statistical data and trends to maintain the highest level of standards.
Assuming responsibility of the Department in the absence of the Department Manager.