Appeals Representative

06/22/2022
Remote
Full Time
Business Management & Administration

Job Description

SUMMARY
The Appeals Analyst reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results.
RESPONSIBILITIES
• Review inquiries to determine if they meet definition of appeal/grievance.
• Request and review all related relevant documentation and assemble case file.
• Coordinate resolution results and relay investigative results with all involved parties.
• Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends.
• May support the Quality Assurance, Appeal and other quality committees.
• Other duties as assigned or requested.
QUALIFICATIONS
• 3-5 years of relevant, progressive experience in the area of specialization. Grandfathered experience requirements effective August 2016.
• Bachelor's Degree preferred, Assoicates required
• Experience in Customer Service or a related field
• Knowledge of multiple processing systems and workflows
• Knowledge of claims processing methodologies
• Ability to interpret all government regulations
• Knowledge of company products
• Excellent organizational skills
• Strong verbal and written communication skills

Additional Details

Experience: 2-5 years