Appeals Specialist I

Position Title : Appeals Specialist I

Work Location : Remote from any location

Assignment Duration : 6+ months

Work Schedule : M-F 8am-5pm CST with 1 hour lunch

Training : Mon-Fri for 4-6 weeks

Position Summary : Responsible for processing, organizing, and coordinating all materials and information relating to processing appeals for all lines of business following federal, state, and accreditation requirements.

Key Responsibilities :

• Complete, organize and oversee the appeal process of the unit to ensure all telephone and written appeals are processed accurately and promptly.
• Coordinate all appeal functions which involves preparing summary reports; categorizing and routing medical appeals to the appropriate departments for action and acting as the liaison with other units regarding appeal issues.
• Accurately respond by telephone, in person, or through correspondence to all inquiries involving requests for appeals.
• Determine need for obtaining additional information and notifying members and / or providers as related to the processing of appeals.
• Respond to appeal requests within designated time requirements.
• Acknowledge member complaints within the regulatory timeframe.
• Compose letter to provider for management approval, track timeliness of response, and send follow-up letters as appropriate.
• Coordinate internal quality of care referral.
• Promote goodwill of our customer population through capable, efficient, caring, and composed performance.
• Coordinate and maintain system of tracking member complaints and appeals which includes identification and resolution of member concerns or outcome of appeal or internal quality of care referral.
• Provider support to supervisor, and appeals RN, and grievance coordinator as necessary.
• Identify trends and communicate this information to the supervisor.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

Qualification & Experience :

Preferred Skills :