Job Description

Were looking forAn Appeals Specialist that will analyze and resolve verbal and written claims and authorization appeals through coordination with providers and members. This position will prepare responses within required timeframes and track the status of all appeals with exemplary record-keeping.Whats the role?You will be responsible for:

• Utilize guidelines and tools to conduct research and analyze appeal issues and relevant claims.

Collect, analyze, and report verbal and written complaints and appeals from members and providers.Analyze and make determinations on assigned appeal issues.Draft response letters for member and provider appeals.Maintain detailed records of all complaints, resolutions, and documentation for tracking and auditing purposes.Serve as a subject matter expert on appeals, ensuring accurate record-keeping and status updates on all appeals.Act as a liaison between members, providers, regulatory agencies, and internal teams; coordinate with key individuals regarding appeal decisions.Work with internal subject matter experts to obtain benefit and/or clinical opinions and interpretations of complex cases.Who are you?

• You have the ability to communicate clearly and professionally with internal and external customers.

You make decisions using available resources and sound judgment.You can identify and resolve problems promptly, gathering and analyzing information effectively.You are have an eye for detail and great time management skillsYou demonstrate accuracy and thoroughness in work, consistently monitoring for quality.You know how to adapt to changes in the work environment, manage competing demands, and handle frequent changes, delays, or unexpected events.You are available to work overtime as required.Boxes to tick

• Matric

Diploma or equivalent; associates degree preferred2+ years grievance and appeals, claims or related healthcare experience, preferably in a carrier or TPA settingFamiliarity with CMS standards and requirements related to complaint resolutionYou are proficient in Microsoft OfficeYou maintain confidentiality and exercise discretion in handling sensitive information.This position entails 3-6 weeks of training which will commence from 2pm-11pmWorking Hours after training: 9am - 6pm

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