What are the responsibilities and job description for the Claims and Appeals Specialist position at Point32Health?
Job Details
The Claims and Appeals Specialist assists with all operational aspects of the Member Appeals and Grievances process for Commercial, TMP, and Public Plans products. This position requires a strong understanding of regulatory requirements and timeframes, as well as the ability to handle each function appropriately and prioritize tasks. The successful candidate will be able to work independently but also identify when they should ask for help. Additionally, flexibility to respond to changing needs in the Department is essential.
Responsibilities
- Enter initial member appeals and grievances data into the system of record and maintain accuracy of appropriate data.
- Outreach to providers for additional information in compliance with CMS guidelines.
- Summarize and send requests to Medical Directors for decisions.
- Complete decision letters and verbal notification of outcomes according to CMS guidelines.
- Process cases according to CMS regulations and time frames.
Requirements
- BA/BS or equivalent in healthcare, administrative, or related field preferred.
- 1-2 years of experience in a healthcare and/or administrative setting preferred.
- Must have computer skills with experience in EXCEL and WORD. Must have knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications. Knowledge of basic medical terminology a plus.
Why Work With Us
- Medical, dental, and vision coverage.
- Retirement plans.
- Employer-paid life and disability insurance with additional buy-up coverage options.
- Full suite of benefits to support career development, individual & family health, and financial health.
About Our Organization
Point32Health is a leading health and wellbeing organization, committed to delivering an ever-better personalized healthcare experience to everyone in our communities.
The Claims and Appeals Specialist assists with all operational aspects of the Member Appeals and Grievances process for Commercial, TMP, and Public Plans products. This position requires a strong understanding of regulatory requirements and timeframes, as well as the ability to handle each function appropriately and prioritize tasks. The successful candidate will be able to work independently but also identify when they should ask for help. Additionally, flexibility to respond to changing needs in the Department is essential.
Responsibilities
- Enter initial member appeals and grievances data into the system of record and maintain accuracy of appropriate data.
- Outreach to providers for additional information in compliance with CMS guidelines.
- Summarize and send requests to Medical Directors for decisions.
- Complete decision letters and verbal notification of outcomes according to CMS guidelines.
- Process cases according to CMS regulations and time frames.
Requirements
- BA/BS or equivalent in healthcare, administrative, or related field preferred.
- 1-2 years of experience in a healthcare and/or administrative setting preferred.
- Must have computer skills with experience in EXCEL and WORD. Must have knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications. Knowledge of basic medical terminology a plus.
Why Work With Us
- Medical, dental, and vision coverage.
- Retirement plans.
- Employer-paid life and disability insurance with additional buy-up coverage options.
- Full suite of benefits to support career development, individual & family health, and financial health.
About Our Organization
Point32Health is a leading health and wellbeing organization, committed to delivering an ever-better personalized healthcare experience to everyone in our communities.
