Appeals and Complaints Specialist

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
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