JOB SUMMARY: Responsible for reviewing and responding to claimant eligibility appeals. This includes conducting necessary research, requesting additional information as needed and preparing a detailed written response of the decision.

Essential Functions: Claims Resolution Specialist 

• Review and resolve claimant and/or eligibility appeals though critical analysis of all medical and claim information related to claimant’s functional status or provider’s qualifications, along with policy language.
• Request appropriate claim documentation needed for appeal review and clarify any discrepant information in a timely manner via telephone and/or written communication
• Present summary and recommendation to Claims Consult Team and/or client when applicable for complex appeal decisioning
• Ensure that all Practice Standards and Training Bulletins were followed during the initial claim adjudication and provide feedback to supervisors when deviations found
• Respond to appeal via detailed written communication outlining information reviewed, policy language and reason(s) for decision, along with all state/regulatory language.
• Continuously keep claimant/representative up to date on status of appeal via telephone and written communication