Appeals Review Specialist

Responsibilities

• Claim edits and reviews
• Verifies claim accuracy compared to medical record
• Reviews claims edit for fraud and abuse
• Escalates claims to Utilization Management Vendor when appropriate
• Appeals/Inquiries
• Reviews, researches, and responds to members and providers in writing regarding questions, complaints or denied coverage objections
• Provides denial explanations
• Responds in writing and/or via phone to all inquiries in an accurate and timely manner
• Customer Service - Internal/External
• Acts as a role model in demonstrating the core values in customer service delivery
• Provides timely and thorough follow up with, internal and external customers
• Sends letters to providers and members explaining a denial
• Appropriately escalates difficult issues up the chain of command
• Quality Assurance
• Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction
• Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters
• Performs self quality monitoring in order to develop and execute plans to meet established goals
• Provides ongoing feedback to help optimize quality performance
• Collaborates with others and cross-departmentally to improve or streamline procedures
• Develops new or improves current internal processes to improve quality
• Compliance
• Maintains regulatory compliance standards

Qualifications

• HS. Diploma or equivalent
• Minimum of two years experience in claims examining or related work experience

Skills and Abilities

• Working knowledge of computers and software including but not limited to Microsoft Office products
• Proficient 10-key and typing skills
• Demonstrated self-motivation, organizational skills, problem-solving skills
• Strong written and oral communication skills with attention to detail and accuracy
• Demonstrated ability to remain neutral and maintain confidentiality

Benefits

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

Pay

Competitive salary commensurate with experience

Schedule

100% remote