Appeals Specialist

Overview

• Support appeals processes within the managed care or health insurance sector, ensuring compliance with regulations and organizational policies.
• Work remotely during standard business hours, providing administrative and clerical expertise in claims and appeals management.
• Utilize SharePoint and other systems to track, manage, and resolve appeals efficiently and accurately.
• Collaborate with team members to ensure timely and professional resolution of disputes and appeals.
• Prepare and manage case files, summaries, and documentation in compliance with HIPAA and organizational standards.
• Engage in critical thinking and decision-making to address complex appeals and disputes effectively.
• Maintain productivity and quality standards while adhering to regulatory deadlines and requirements.
• Contribute to the Independent Dispute Resolution (IDR) process, ensuring equitable and prompt resolution of payment conflicts.

Key Responsibilities & Duties

• Monitor submissions and timelines for the IDR process, ensuring compliance and timely resolution of disputes.
• Prepare, edit, and finalize case files, letters, and summaries with accuracy and professionalism.
• Manage responsibilities within regulatory timeframes, maintaining adherence to organizational policies and standards.
• Collaborate effectively with colleagues to ensure efficient workflow and successful outcomes.
• Build evidence packets following job aids, ensuring correct order and attachments.
• Verify accuracy in OnBase cases, including service levels, authorization numbers, and member demographics.
• Submit packets to external entities via FTP, ensuring compliance with submission deadlines.
• Perform additional duties as assigned to support appeals and dispute resolution processes.

Job Requirements

• High School Diploma or GED from an accredited institution is required.
• Minimum of 2 years of experience in managed care, health insurance, or appeals preferred.
• Proficiency in claims management, customer service, or healthcare settings is advantageous.
• Familiarity with systems such as SharePoint, OnBase, TruCare, or Hyland is preferred.
• Strong critical thinking, decision-making, and communication skills are essential.
• Ability to work under pressure, meet deadlines, and maintain attention to detail.
• Knowledge of HIPAA compliance and regulatory standards is required.
• Experience in appeals management and dispute resolution processes is beneficial.