Senior Appeals Representative

This is a fully remote position, open to applicants in Florida, +3 more locations.

📋 Description

• Conduct investigations and reviews of customer appeals concerning service provision and benefit coverage issues.

• Assess and prioritize clinical and non-clinical inquiries, grievances, and appeals.

• Compile case files for member grievance committees and hearings.

• Summarize and present critical information to clinical specialists, medical directors, and legal counsel.

• Address both oral and written complaints.

• Resolve inquiries, grievances, and appeals within designated regulatory, accreditation, or customer-specified timelines.

• Reach out to customers to collect information and communicate case outcomes; ensure documentation of interactions.

• Create written correspondence to members, providers, and regulatory agencies.

• Identify obstacles to customer satisfaction and suggest measures to tackle operational challenges.

• Engage in continuous education and training regarding benefits and services.

• Log and document inquiry, appeal, and grievance information in tracking systems.

• Address complex customer issues requiring customized responses or thorough research.

• Make administrative exceptions according to established guidelines.

• Investigate, summarize, and propose resolutions for non-clinical cases.

• Support grievance and appeals staff with file decisions.

• Offer direction and guidance to team members.

• Exhibit leadership and cultivate a supportive environment.

• Undertake other related duties as necessary.

⛳️ Requirements

• High school diploma or its equivalent.

• At least 4 years of relevant experience in grievances and appeals.

• Alternatively, any combination of education and/or experience that provides an equivalent background.

• Foreign national applicants must have resided in the United States for a minimum of three out of the past five years.

• Knowledge of the application of benefits contracts, pricing, policies, and legislative regulations.

• Strong verbal and written communication skills.

• Excellent organizational skills.

• Strong interpersonal skills.

• Proficiency in PC usage is strongly preferred.

• Familiarity with appeals processes is preferred.

• Knowledge of Part A and B Medicare is preferred.

• Candidates must live within a reasonable commuting distance from the posting location(s), unless accommodations are provided as required by law.

• Certain patient/member-facing positions require vaccination against COVID-19 and Influenza.

🏝️ Benefits

• Merit increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• Short-term disability benefits.

• Long-term disability benefits.

• 401(k) with matching contributions.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.

• Virtual full-time work, except for mandatory in-person training sessions.

• Continuous education and training opportunities.