Appeals Specialist

• Coordinate the formal provider appeals process both internally for first level and externally for second level appeals. This includes preparing and sending letters scheduling and leading the appeal meeting and drafting and sending resolution.
• Coordinate the informal provider payment dispute process and determine the necessary actions to resolve the problem.
• Coordinate the member grievance and appeal process with Appeals Coordinator. This includes member contact and coordination (verbal and written correspondence) tracking grievances and appeal scheduling and leading Grievance and Appeal Committee clinical consultations with the Health Management Department and internal and external reporting.
• Coordinate member complaint process. This includes member contact and coordination (verbal and written correspondence) tracking complaints scheduling and leading Grievance and Appeal Committee and internal and external reporting
• Research and resolve complex claims that pertain to membership or billing issues; send claim and payment reversals to appropriate staff if necessary.
• Work closely with the Internal Coder and Claims management team to resolve billing issues. Provide education to providers if appropriate.
• Appeals Specialist will review all decisions and generate resolution letters for member and provider appeals.

• Excellent verbal and written communication skills required;
• One to two years of customer service experience focusing on customer complaint resolution is preferred;
• Bachelors degree preferred or equivalent experience required;
• Knowledge of the health insurance industry preferred;
• Organized and attentive to detail;
• Proficiency with Microsoft Word Excel is required.
• Ability to work well with many different personality types;
• Excellent work ethic with the ability to work in a team environment as well as independently;
• Strong analytical and problem solving skills.

Required Experience:

IC