IDR Resolution Specialist

HealthFirst

6d•$51,000 - $80,070

About The Position

The Appeals Review Specialist is responsible for independently managing a caseload, preparing appeal packets for external review, and ensuring timely, compliant resolutions in accordance with state and federal regulations. This role requires that appeal cases and independent review inquiries are processed, accurately, thoroughly, and within required timeframes while upholding company polices and regulatory standards. The specialist will serve as a point of contact with various regulators, entities and providers to ensure that request are handled accurately and timely while upholding company policies and regulatory standards.

Requirements

HS Diploma or GED from an accredited institution
Experience in claims, customer service, or healthcare settings
Collaborative
Detail-oriented, able to work under pressure, and meet tightlines
Ability to work under pressure
Organized

Nice To Haves

Previous experience in managed care, health insurance, or appeals.
Familiarity with systems such as OnBase, TruCare, or Hyland.
Strong critical thinking, decision-making, and communication skills.

Responsibilities

Research issues and apply Healthfirst policies, procedures, and regulations.
Prepare, edit, and finalize case files, letters, and summaries.
Manage all duties within regulatory timeframes.
Manage the Independent Dispute Resolution (IDR) process by effectively monitory submissions, timelines and ensuring compliance to achieve fair and timely resolution of payment disputes .
Communicate and collaborate effectively with colleagues.
Efficiently manage the external appeal process from beginning to effectuation of the resolution of the external appeal decision.
Ensure accuracy in OnBase cases, including: Correct org received/decision date and time. Proper setup as Pre- or Post-service. Verification of service level and authorization number. Accurate member and submitter demographics. Complete provider details with address. Complete case summaries with all fields checked and service level validated. Confirm inclusion of required documents (assessments, denial rationale, EOC excerpts, redacted pages).
Gather information from OnBase, TruCare, and other systems; maintaining accurate case management.
Build evidence packets per job aid (AG-RF-208), ensuring correct order and attachments.
Submit packets to OAH via FTP by due date and upload proof of submission upon acknowledgement.
Maintain productivity, quality standards, and HIPAA compliance.
Perform additional duties as assigned.