Job Title: Appeals Specialist I

Duration: 5+ Months

Location: Remote

Shift: M-F 9am-6pm EST with 1 hour lunch

Basic function:

Under supervision, this position is 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; and for accurately responding by telephone, in person, or through correspondence to all inquiries involving requests for appeals from members, the Department of Labor, or ERISA; sending acknowledgement letter to member and draft provider letters for directors' signature; entry of appeals into appropriate database; and processing of internal quality of care referrals.

Essential functions: 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.

Job requirements: 2 years' experience researching and responding to telephone and / or correspondence inquiries regarding health insurance claims/services OR 1 year health insurance plus 2 years of customer service experience. Effective analytical, problem solving and research skills. Effective organizational skills to accommodate large volume of reference materials combined with time management skills to achieve accessibility to callers. Effective verbal and written communication skills to include the ability to clearly express oneself in a well-modulated tone with correct grammar and attention to enunciation.

Preferred Job Requirements : BlueChip claims payment experience. Medical terminology. Knowledge of appeals processing. Ability to think clearly and maintain a professional, poised attitude under pressure. Detail oriented. Bi-lingual Spanish speaking.