Appeals Specialist

HealthFirst

12d•$51,000 - $80,070

About The Position

The Appeals & Grievances (A&G) unit processes member and non-contracted provider appeals for all of HF’s line of businesses which include commercial, Medicaid, dual enrollments, Medicare and complete care. Appeals Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. They manage their own caseload and is accountable for investigating and resolving member or non-contracted provider-initiated cases.

Requirements

HS Diploma or GED from an accredited institution
Minimum of two (2) years of work experience in Managed Care Health Insurance Plan
Experience with appeals for Medicare, Medicaid, Dual enrollment and commercial Plans end to end.
Claims processing experience with coding criteria is preferred. This includes the auto forwarding of upheld cases to the respective regulatory independent reviewer for denied cases.

Nice To Haves

Bachelor’s degree from an accredited institution or relevant work experience
Demonstrated critical thinking and decision-making competencies
Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes

Responsibilities

Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals.
Research issues
Reference and understand HF’s internal health plans’ policies and procedures to frame decisions
Interpret regulations
Resolve cases and make critical decisions
Edit and finalize resolution letters
Manage all duties within regulatory timeframes
Communicate effectively to hand-off or pick-up work from colleagues
Work within a framework that measures productivity and quality for each Specialist against expectations
Work independently exercising judgment starting the case development with the respective internal and external entities in the timeframe prescribed in the Job Aid and/or regulatory timeframes.
Prepare and submit well documented appeals in accordance with payer guidelines and within timely filing limits
Identify patterns or trends in denials and provide feedback for leadership for process improvement.
Remain up to date on payer polices, industry regulations and coding updates to ensure compliance and maximize reimbursement
Additional duties as assigned