Appeals Specialist II

This is a fully remote position, open to applicants in United States.

📋 Description

• Support Appeals leadership with daily administrative tasks within the department.

• Conduct research, investigations, and analyses of appeals, grievances, and various complaints submitted by providers and clients to ensure prompt resolution.

• Manage all aspects of nonclinical appeals and inquiries.

• Prepare and distribute case files for External Reviews and/or State Fair Hearings.

• Oversee and track all appeals from Non-Participating providers.

• Independently craft well-written, tailored responses to all provider inquiries/complaints that adequately and fully address the issues raised by the complainant and maintain structural accuracy.

• Ensure timely assessment, research, and resolution of appeals, grievances, and complaints in accordance with guidelines.

• Collaborate with managers on complex cases and interact with clinical supervisors, account managers, and other staff members to resolve health plan requests or provider inquiries.

• Log and monitor grievances, appeals, and other complaints as necessary.

• Review and determine the outcome of appeals/grievances, either independently or in collaboration with clinical appeal staff.

• Consult with subject matter experts and utilize internal resources to aid in the resolution of appeals and complaints.

• Make critical decisions regarding research and investigations to effectively resolve all inquiries.

• Act as a liaison to the Appeal Coordinator, providing guidance and expertise to ensure timely case resolution.

⛳️ Requirements

• Associate's Degree. Additional relevant experience may substitute for educational requirements.

• Over 3 years of experience in the healthcare sector.

• Preferred experience in inpatient claims, DRG, and High-Cost Outlier claims.

• Familiarity with DRG Pricing using WebStrat.

• Understanding of claim payment methodologies.

• Proficient in MS Office, particularly Excel.

• Strong problem-solving and analytical skills are essential.

• Ability to prioritize tasks in a complex environment; exceptional organizational and time management skills are required.

• Excellent written and verbal communication abilities.

• Proactive in identifying and resolving issues.

• Capability to meet strict, time-sensitive deadlines.

• Ability to handle ambiguity and stressful situations effectively.

• Must demonstrate patience and the ability to stay calm under pressure in an environment with frequent interruptions.

🏝️ Benefits

• Healthcare that suits your needs - We provide outstanding medical, dental, and vision plan options that cover employees and their dependents.

• 401(k) with Employer Match - Join our team and we will contribute to your future.

• Generous Paid Time Off - Accrued PTO from day one, in addition to extra days off when you’re unwell, and to celebrate holidays.

• Wellness - We prioritize your well-being. From Commuter Benefits to FSAs, we've got you covered.

• Learning & Development - Through ongoing education/mentorship on the job and our commitment to LinkedIn Learning, we focus on your growth as a professional.