Appeals Specialist

The Appeals Specialists investigates the appeal requests, gathers all pertinent information to ensure the appeals committee can provide an accurate and fair determination.

Completes the determination letter and follows through with completing appeals within the specified compliance timeframe.

* Thoroughly investigates and responds to written/verbal appeal requests submitted by members or providers on behalf of members.

* Documents investigative steps including outcomes of discussions with other business areas, and any interactions with members or the provider related to the case.

* Uses multiple systems to conduct investigations in accordance with Centers for Medicare and Medicaid ("CMS") guidelines as well as applicable guidelines established by State and other regulatory agencies.

* Reviews appeal case documentation within the appeal management system to ensure all data is accurately entered and makes updates as needed.

* Makes member outreach calls to answer questions, provide guidance, and clarify information regarding the appeal request.

* Resolves appeals in accordance with the member benefits, claims payment, and medical policies as well as guidelines established by applicable regulatory agencies * Ensures case documentation thoroughly supports the outcome of the appeal * Creates and Reviews Appeals Determination letters ensuring all state, federal, and NCQA standards are met as applicable * Outreaches to appropriate business area to ensures appeal effectuations for overturned appeals are completed timely * Monitors caseload daily to ensure cases are kept within compliance timeframes * Performs other duties as assigned * Bachelors degree preferred * Minimum of 2 years experience in a payor operations or investigative area; preferred experience in claims, utilization management, or provider network services * Has a good understanding of the company's products and benefit structures * Proficient in Microsoft office products such as Excel, Word, Outlook * Excellent interpersonal skills to interact with internal and external customers * Self-motivated, organized, detail oriented * Excellent Written and verbal communication skills * Ability to work through complex issues