Job Responsibilities
- Reference and understand internal health plans’ policies and procedures to frame decisions
- Interpret regulations
- Resolve cases and make critical decisions
- Edit and finalize resolution letters
- Manage all duties within regulatory time-frames
- Communicate effectively to hand-off or pick-up work from colleagues
- Work within a framework that measures productivity and quality for each Specialist against expectations
- Additional duties as assigned
Minimum Qualifications
- Bachelor’s degree from an accredited institution or relevant work experience
Preferred Qualifications
- Perform detailed analysis of Appeals and complaints adhering to policy language and responding
within the state/federal required timeframes; - Respond to the acknowledgment of Appeals and complaints within state/federal required timeframes;
- Following up on inquiries and task assignments to various departments to completion;
- Logging documentation in and out of the Appeal system;
- Gathering documentation needed to respond to complaints;
- Ability to multitask and meet deadlines;
- Strong understanding of COB, ACA, HIPAA Privacy, an understanding of benefits and claims
payment;