Appeals Specialist

Devoted Health•Waltham, MA

2d•$23 - $30•Remote

About The Position

The Appeals Specialist is an integral member of the Appeals Operations team and the broader Provider Escalations & Educations team. The role is responsible for timely processing and effective decision-making on appeals submitted by plan providers, non-contracted providers, members, or their appointed representatives. The specialist works cross-functionally with Clinical, Medical Directors, Utilization Management, and claims teams to support appropriate appeal-review decisions.

Requirements

Strong computer, analytical, oral, and written communication skills.
Bachelor’s degree or equivalent experience in health care, conflict resolution, or a related field.
Detail-oriented, with strong attention to data integrity and documentation.

Nice To Haves

Superior investigation, customer service, interpersonal, and problem-solving skills.
Working knowledge of insurance products, policies, procedures, and the claims process.

Responsibilities

Correspond with members and/or providers through written communications and telephone contact, and document interactions as appropriate.
Coordinate with managers, internal departments, and external vendors on appeal investigation, review, resolution, and research needed to prepare cases for internal or external review.
Manage the receipt, investigation, and resolution of appeals in a timely, compliant, and effective manner.
Maintain current knowledge of Devoted Health products, policies, and procedures, and explain this information clearly to members, providers, and other internal and external individuals.
Complete data entry and documentation in multiple systems to ensure required CMS universe details are captured appropriately.