The Appeals Specialist III will be responsible for assisting the Manager, Supervisors, and Business Analysts or Operations Coordinators with unit projects, quality audits, and overall operational functions. Responsible for the initial analysis of appeals correspondence, determining next steps, collecting, organizing and tracking information to facilitate and expedite processing of appeals received from a variety of sources. Serves as subject matter expert. Able to provide short term or interim coverage for high level complicated cases that require detailed research and analysis.
Determines appropriate action required by prioritizing, researching and analyzing information to successfully complete initial inquiries and be accountable for accurate and timely case entry and assignment. Leads a team in the analysis of existing business processes and systems to identify, document, elevate the presence of risks and trends within systems and processes that may be noncompliant with requirements for proper appeals handling. Analyzes and researches necessary information for high profile cases in a timely or expeditious manner including written responses to governmental agencies.
Consistently develops accurate professional written communications and verbal interaction with internal and external stakeholders. Reviews and researches complicated or high profile correspondence with Supervisor as necessary. Will articulately present and discuss compliance as needed and exhibit sound judgement in determining a recommendation or solution to an identified problem.
Independently researches contractual benefits, limitations & exclusions and claims related cases as a subject matter expert to assist medical professional staff in performing the review of appeals and reconsiderations. A subject matter expert for internal stakeholders, particularly in specialized appeal areas. Recognizes and acknowledges time sensitive or escalated requests and tasks and acts as a liaison for other departments and company stakeholders to complete Regulatory complaints, internal and external audits and other projects as needed.
Provides support and acts as a trainer and mentor to entry level associates including Appeals Specialists I & II. Designs and provides effective training programs for internal customers who need education on the appeals process. Develops and provides information, training and education for appeals associates at Staff, R &T and Nurse Forums. Performs other duties such as committee work and special projects.
QualificationsTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: High School Diploma
Experience: 5 years experience in settings such as managed care, health care or insurance payor environment 3 years experience in Clinical Appeals and Analysis Unit including 2 years experience as an Appeals Specialist II
In Lieu of Education
Preferred QualificationsCollege Degree
Knowledge of *** system, Member/Provider Service, Claims or Care Management experience a plus.
Leadership Experience