Appeals Specialist

About the role

As an Appeals Specialist at MVP Health Care, you will play a crucial role in the nuanced landscape of healthcare, insurance or other related fields, focusing on reviewing and processing appeals related to service or coverage denials.

The role demands a meticulous approach to understanding policies, regulations and specific circumstances surrounding each case. The Appeals Specialist ensures that every appeal is evaluated thoroughly and fairly, based on the merits of the case and applicable guidelines.

Your efforts are instrumental in upholding the integrity of the decision-making process, ensuring that each party's rights are respected and the resolutions are reached in a timely manner. In this position, you contribute to the overall satisfaction and trust of the stakeholders involved, while also maintaining standards and reputation of MVP Health Care.

Qualifications

• Bachelor's degree in law, healthcare administration, business or related field required
• Associate's Degree with minimum 5 years' healthcare experience in lieu of Bachelor's Degree
• Strong attention to detail and ability to manage multiple tasks simultaneously
• Excellent communication skills, both written and verbal
• Exceptional customer service skills and ability to handle difficult situations with empathy and professionalism
• Proficient in using computer systems and software, including Microsoft Office Suite
• Ability to work independently and as part of a team in a fast-paced environment
• Strong organizational and time management skills

What You'll Do

• Review and analyze appeals requests ensuring that the cases are eligible for appeal
• Investigate and review routine and complex appeals
• Ensure compliance with State and Federal regulations, including accreditation requirements (e.g.: CMS, Medicaid, NCQA)
• Collaborate with internal and external stakeholders, as well as liaise with providers and enrollees as necessary to gather necessary documentation and information for appeals processing
• Maintain accurate and up-to-date records of appeals, including documentation of all communication in the department's tracking system
• Monitor and track status of appeals, ensuring cases are processed within specified timeframes
• Prepare all appeals correspondence (acknowledgment, extension and resolution)
• Aid clients in understanding the appeals process and provide guidance on next steps
• Handle customer inquiries and resolve issues related to Medicare appeals in a professional and efficient manner
• Identify opportunities for process improvement and contribute to the development and implementation of best practices
• Stay updated on changes in regulations and guidelines to ensure compliance and provide accurate information to enrollees
• Analyze appeal outcomes to identify trends, patterns, issues with denials, recommending process improvement