Appeals Specialist

Sun Life • Milwaukee, WI

2d

About The Position

The opportunity: The Appeal Specialist is responsible for the investigation and resolution of all administrative and clinical appeals based upon specific regulatory and or client requirements. In addition, this position is responsible for the assembly and preparation of responses to clients, members and/or providers. This position is responsible for daily interaction with assigned market/client contacts, as well as various internal departments. This position is also responsible to ensure that all mandated turnaround times are met as well as required processes and workflows are adhered to.

Requirements

• High School Diploma or GED required.
• 1+ years experience in healthcare operations or appeals; or related field.
• Proficient with general computer software including Microsoft Excel, Word and Outlook.
• Excellent verbal, written, interpersonal, organizational and communication skills.
• Excellent research skills with ability to identify underlying issue(s) even if not articulated.
• Ability to remain calm and focused in a high pressure/high workload environment.
• Ability to work in a high stress environment.
• Ability to prioritize and organize multiple tasks with tight deadlines.
• Ability to remain organized with multiple interruptions.
• Ability to work overtime as needed or required to meet business objectives.
• Other duties, as assigned as they relate to complaints and grievances.

Nice To Haves

• Previous experience in claims billing or prior authorizations
• Bachelor’s degree in business, healthcare or equivalent
• Keyboarding skills.

Responsibilities

• Investigate, document and resolve member and provider appeals and inquiries related to appeals in accordance with State and/or Plan guidelines.
• Ensure all components of the appeal or request for information are researched and addressed.
• Assemble necessary information for the client so they may appropriately investigate an appeal when DentaQuest is secondary. If contracted to do so, also investigate the appeal and provide recommended outcome and appropriate correspondence.
• Monitor shared mailboxes and department e-mails to ensure cases are properly entered into department tracking system, and that requests are acknowledged and resolved timely and accurately.
• Manage workflow to meet department, Plan, State, and company goals and deadlines.
• Comply with and complete any client directives or overturns.
• Collaborate and partner with Complaint & Grievance team to resolve common issues oor trends.
• Take the lead in working with other internal departments/management team to ensure that any trends identified in appeals are communicated and rectified.
• Keep abreast of changes in market requirements and demonstrate expert knowledge in specific market nuances.
• Identify and resolve issues that are unusual and not consistent with standard workflows.
• Attend client or market meetings as assigned and share any new issues/changes that may be impactful.
• Establish and maintain professional relationships with Plan contacts.
• Contact involved provider office to obtain information to properly review the case.
• Document and summarize member’s and provider’s concerns / issues in a concise and easily readable format.
• Ensure all letter templates in use are correct and most recent versions are used.
• Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management.
• Other duties as assigned.

Benefits

• At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program.
• Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account.
• Enjoy a flexible, inclusive and collaborative work environment that supports career growth.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees