Appeals Specialist I

Job Title - Appeals Specialist I

location - Fully remote 

Bi-lingual Spanish speaking

Anywhere (EST/CST)



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 director?s signature; entry of appeals into appropriate database; and processing of internal quality of care referrals.



ESSENTIAL FUNCTIONS:1. Complete, organize and oversee the appeal process of the unit to ensure all telephone and written appeals are processed accurately and promptly.2. 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 appealissues.3. Accurately respond by telephone, in person, or through correspondence to all inquiries involving requests for appeals4. Determine need for obtaining additional information and notifying members and/or providers as related to the processing of appeals.5. Respond to appeal requests within designated time requirements.6. Acknowledge member complaints within the regulatory timeframe.7. Compose letter to provider for management approval, track timeliness of response, and send follow-up letters as appropriate.8. Coordinate internal quality of care referral.9. Promote goodwill of our customer population through capable, efficient, caring, and composed performance.10. 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.11. Provider support to supervisor, and appeals RN, and grievance coordinator as necessary.12. Identify trends and communicate this information to the supervisor.13. Communicate and interact effectively and professionally with co-workers, management, customers, etc.14. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.15. Maintain complete confidentiality of company business.16. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.



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.*



Hust have 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.*