Appeals Specialist I

Job Title: Appeals Specialist I
Location: Remote, TN
Duration: 1 + Months (Possibilities of Extension)
 
Schedule: Thursday–Sunday, 7:30 a.m. – 6:30 p.m. CST (1-hour lunch)
Training Update: raining will be Monday–Friday for 4–6 weeks, with the only days off being Client holidays.
 
Basic Function:
Under supervision, this position is responsible for processing, organizing, and coordinating all materials and information relating to the processing of appeals for all lines of business, following federal, state, and accreditation requirements. The role includes 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 letters to members and drafting provider letters for director’s signature; entering appeals into the appropriate database; and processing 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 involve preparing summary reports; categorizing and routing medical appeals to the appropriate departments for action; and acting as a liaison with other units regarding appeal issues.
• Accurately respond by telephone, in person, or through correspondence to all inquiries involving requests for appeals.
• Determine the 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 letters to providers for management approval, track timeliness of responses, and send follow-up letters as appropriate.
• Coordinate internal quality-of-care referrals.
• Promote goodwill among the customer population through capable, efficient, caring, and composed performance.
• Coordinate and maintain a system of tracking member complaints and appeals, including identification and resolution of member concerns or outcomes of appeals or internal quality-of-care referrals.
• Provide support to the supervisor, 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 developments within areas of assigned responsibilities and perform special projects as required or requested.

 
Job Requirements:

• 2 years of experience researching and responding to telephone and/or correspondence inquiries regarding health insurance claims/services, OR 1 year of health insurance experience plus 2 years of customer service experience.
• Effective analytical, problem-solving, and research skills.
• Strong organizational skills to manage a large volume of reference materials and the ability to manage time effectively to ensure accessibility to callers.
• Excellent verbal and written communication skills, including 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.
• Knowledge of medical terminology.
• Familiarity with appeals processing.
• Ability to think clearly and maintain a professional, composed attitude under pressure.
• Detail-oriented.
• Bilingual (Spanish/English) preferred.