Appeals Specialist IIThe Appeals Specialist II will be responsible for the initial intake, analysis of appeals/grievances correspondence, and determination of next steps, with minimal supervision for Government Program lines of business. Responsible for collecting, organizing and tracking information to facilitate and expedite processing of appeals and grievances received from a variety of sources. Responsible for more complicated, high level research of cases, and other special projects as well as serving as a subject matter expert. Provides resolution to problems that are readily identifiable with limited scope and are resolved in accordance with standard practices, procedures, applications or routines. Problem/Task resolution timeframe: The majority of tasks typically take one to two days to resolve. Under general supervision, proceeds alone or regular duties, referring questionable cases to supervisor. Failure to accomplish results can normally be overcome without significant effect on the organization Contacts are primarily within the department or function with occasional cross-functional interfaces. Some limited external customer contact on routine matters.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level:
High School Diploma or GEDEducation Details: Experience: 5 years experience in settings such as managed care, health care or insurance payor environment 2 years experience in Appeals Management Preferred Qualifications College Degree Knowledge of Client system, Member/Provider Service, Claims or Care Management experience a plus.
Knowledge, Skills and Abilities:
(KSAs) Research and Problem Solving Skills, Ability to lead, train, coach and mentor less experienced team members., Ability to work both independently and as a member of a team with minimal supervision., Excellent organizational and analytical skills. Knowledge and understanding of medical terminology.
