Appeals Specialist

Group Health Cooperative•Altoona, PA

2d•Onsite

About The Position

The Appeals Specialist will be responsible for the appeals process from receipt to resolution for both provider appeals and member appeals, grievances, and complaints. This position will research and resolve complex issues related to claims and enrollment, provider payment disputes, reversals, member authorization denials, and service quality complaints. The Appeals Specialist will schedule member appeals and lead the Grievance and Appeal Committee meetings for members to appeal authorization denials and/or quality complaints. Finally, this position is responsible for tracking and reporting on data related to these processes.

Requirements

Excellent verbal and written communication skills required
Bachelor’s degree preferred or equivalent experience required
Organized and attentive to detail
Proficiency with Microsoft Word, Excel is required
Ability to work well with many different personality types
Excellent work ethic with the ability to work in a team environment as well as independently
Strong analytical and problem solving skills

Nice To Haves

One to two years of customer service experience focusing on customer complaint resolution is preferred
Knowledge of the health insurance industry preferred

Responsibilities

Coordinate the formal provider appeals process both internally for first level and externally for second level appeals. This includes, preparing and sending letters, scheduling, and leading the appeal meeting, and drafting and sending resolution.
Coordinate the informal provider payment dispute process and determine the necessary actions to resolve the problem.
Coordinate the member grievance and appeal process with Appeals Coordinator. This includes member contact and coordination (verbal and written correspondence), tracking grievances and appeal, scheduling and leading Grievance and Appeal Committee, clinical consultations with the Health Management Department, and internal and external reporting.
Coordinate member complaint process. This includes member contact and coordination (verbal and written correspondence), tracking complaints, scheduling and leading Grievance and Appeal Committee, and internal and external reporting.
Research and resolve complex claims that pertain to membership or billing issues; send claim and payment reversals to appropriate staff if necessary.
Work closely with the Internal Coder and Claims management team to resolve billing issues.
Provide education to providers if appropriate.
Review all decisions and generate resolution letters for member and provider appeals.