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Appeals Specialist

Group Health Cooperative
  • Altoona, Pennsylvania
    14 days ago

    Job Description

    Position Purpose
    The Appeals Specialist will be responsible for the appeals process from receipt to resolution for both provider appeals and member appeals, grievances, and complaints.  This position will research and resolve complex issues related to claims and enrollment, provider payment disputes, reversals, member authorization denials, and service quality complaints.  The Appeals Specialist will schedule member appeals and lead the Grievance and Appeal Committee meetings for members to appeal authorization denials and/or quality complaints.  Finally, this position is responsible for tracking and reporting on data related to these processes.  This position will report to the Director of Provider Relations.

    Essential Position Functions
    • Coordinate the formal provider appeals process both internally for first level and externally for second level appeals.  This includes, preparing and sending letters, scheduling, and leading the appeal meeting, and drafting and sending resolution. 
    • Coordinate the informal provider payment dispute process and determine the necessary actions to resolve the problem.
    • Coordinate the member grievance and appeal process with Appeals Coordinator.  This includes member contact and coordination (verbal and written correspondence), tracking grievances and appeal, scheduling and leading Grievance and Appeal Committee, clinical consultations with the Health Management Department, and internal and external reporting. 
    • Coordinate member complaint process.  This includes member contact and coordination (verbal and written correspondence), tracking complaints, scheduling and leading Grievance and Appeal Committee, and internal and external reporting
    • Research and resolve complex claims that pertain to membership or billing issues; send claim and payment reversals to appropriate staff if necessary.
    • Work closely with the Internal Coder and Claims management team to resolve billing issues. Provide education to providers if appropriate.
    • Appeals Specialist will review all decisions and generate resolution letters for member and provider appeals.
    Minimum Requirements of the Position
    • Excellent verbal and written communication skills required;
    • One to two years of customer service experience focusing on customer complaint resolution is preferred;
    • Bachelor’s degree preferred or equivalent experience required;
    • Knowledge of the health insurance industry preferred;
    • Organized and attentive to detail;
    • Proficiency with Microsoft Word, Excel is required. 
    • Ability to work well with many different personality types;
    • Excellent work ethic with the ability to work in a team environment as well as independently;
    • Strong analytical and problem solving skills.
    Group Health Cooperative of Eau Claire complies with applicable Federal civil rights laws and does not discriminate, exclude or treat candidates less favorably on the basis of race, color, national origin (including limited English proficiency and primary language), age, disability, or sex (including sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity; and sex stereotypes).

    The Cooperative is committed to fostering a caring and compassionate environment while ensuring that individual differences are valued. The Cooperative is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. It is essential that all employees and members feel secure and welcome, that the opinions and contributions of all individuals are respected and that all voices are heard.

    This full time position offers an outstanding benefit package, including three weeks of vacation the first year, a generous retirement plan, health and dental insurance, a wellness program, and much more! If you are interested in working for an organization focused on a team atmosphere and is dedicated to providing exceptional service submit your resume today! Send resume to: resumes@group-health.com. Group Health Cooperative of Eau Claire is an affirmative action and equal opportunity employer. 
     

    Numbers & Facts

    LocationAltoona, Pennsylvania
    Websitehttps://www.group-health.com/Careers.aspx

    Skills

    • Billingunmatched
    • Claims Managementunmatched
    • Communication Skillsunmatched
    • Customer Relationsunmatched
    • Customer Support/Serviceunmatched
    • English Languageunmatched
    • Federal Laws and Regulationsunmatched
    • Health Insuranceunmatched
    • Mail Processingunmatched
    • Microsoft Excelunmatched
    • Microsoft Wordunmatched
    • Needs Assessmentunmatched
    • Organizational Skillsunmatched
    • Presentation/Verbal Skillsunmatched
    • Problem Solving Skillsunmatched
    • Process Managementunmatched
    • Provider Relationsunmatched
    • Resolve Customer Issuesunmatched
    • Team Playerunmatched
    • Training/Teachingunmatched
    • Writing Skillsunmatched

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