Appeals and Dispute Support Specialist - Claims Administration

Job Requirements

Position Summary

Ensures all incoming correspondence is properly identified and evaluated for appropriate routing within the Health Plans Operations and within regulatory timeframes. Prepares all member and provider appeals, grievances and disputes for clinical review, reconsideration and handling for coordinators and clinical review while identifying opportunities or deficiencies contributing to member and provider dissatisfaction.

Primary Accountabilities

• Identify critical aspects of incoming correspondence to include: a member’s plan, contract, and benefits; a provider’s network status; and benefit limitations and/or exclusions
• Identify trends with inappropriate requests and escalates to supervisor.
• Maintain confidentiality at all times, following departmental and organizational confidentiality guidelines
• Appropriately distinguish between a grievance request, inquiry, coverage request, a dispute and an appeal for appropriate triaging of casework.
• Actively identify opportunities for lean process improvement for current workflows
• Actively participate in process improvement projects
• Lead change activities related to process and workflow
• Proactively resolve escalated issues
• Drive organizational success by exceeding departmental goals
• Provide exceptional customer centric interactions with other departments
• Assist Health Plans customers in a caring and knowledgeable manner, representing the organization as a skilled health professional
• Handle incoming health plan correspondence and appropriately identifying and evaluating for appropriate routing to departments within the Health Plan.

Work Experience

MINIMUM QUALIFICATIONS

• Education: HS or GED
• Licensure: None Required
• Certification: None Required
• Work Experience: One year experience in a health care setting, customer service or claims
• Knowledge/Skills/Abilities:

• Advanced knowledge of insurance benefits for all lines of business
• Advanced knowledge of medical benefits and terminology

PREFERRED QUALIFICATIONS

• Education: No additional education required
• Licensure: None
• Certification: None
• Work Experience: None
• Knowledge/Skills/Abilities: None

PHYSICAL REQUIREMENTS

Sedentary – Office Workers

• Sedentary work involves sitting most of the time
• Walking and standing or lifting more than 10 pounds are required only occasionally
Must be able to tolerate long periods of computer time a day

Benefits

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.

Schedule : Full-Time

Shift Times : 800am_500pm