Appeals Specialist at Health Advocate, Remote Job $51,000 – $68,000 a year

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Full Job Description

The Appeals Specialist assists clients, members, and prospects with health insurance appeals. Analyze and research denied medical claims and lead efforts to resolve claims issues on behalf of the member. Process appeals within federally mandated timeframes. Escalate claims with managerial levels of insurance carriers or group administrators through key contacts.

The Appeals Specialist will be able to handle complex issues with minimal supervision. Establish and maintain key contacts with insurance carriers, negotiate fees on behalf of Health Advocate members, and appeal denied claims through the appropriate channels.

The Appeals Specialist will be in regular contact with insurance carrier key management, federal and state regulatory offices, members, Human Resource Departments, key clients, and physician office managers.

Essential Job Functions

• Achieve/exceed Call Center Metrics (ASA – <30 seconds; Abandon Rate <5%)
• Identify target resolution for all member calls and then, if possible, ensure cases close at or near the target resolution
• Inform members of your plan of action, expected results, and timeframes, then meet or exceed those timeframes
• Build confidence in our services to encourage members to call back with future questions
• Allay member anxiety and frustration
• Add value to our services by going beyond the member’s initial request
• Advocate for the member to receive coverage for the appropriate medical procedures, medications, and inpatient/outpatient treatment
• Establish and maintain a network of key contacts within insurance carriers, federal and state offices, and the health insurance industry
• Escalate members’ unpaid claims through key contacts
• Assist members in appealing denied claims verbally or in writing when appropriate, including preparing the member for oral appeals hearings
• Lead appeals process within federally mandated timeframes in cases where the member’s attempts have failed
• Serve as subject matter expert in the interpretation of health insurance plan language and state and federal regulation
• Negotiate fees on behalf of the member including facilitating communication between the member and the billing agent
• Research denied claims and verify proper coding
• Education members on their insurance plan provisions
• Assist internal staff in complicated claims related cases
• Document all cases in case management system using the SOAP method (Subjective, Objective, Assessment, Plan) when appropriate

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Requirements

• Five or more years’ experience in health benefits or health insurance appeals preferred
• Understanding of health plan authorizations, including medical policy and claims payment guidelines to evaluate if appeals require clinical or administrative review
• Knowledge of applicable law and resources regarding confidentiality of privileged patient information and appeals administration
• Knowledge of procedure and diagnosis coding (ICD-9, HCPCS, and CPT-4)
• Familiarity with various types of health insurance coverage, coordination of benefits, and UCR fees
• Experience in reviewing, interpreting, and researching Explanation of Benefits (EOB’s) and denial letters
• Experience in identifying contractual appeal timeframes
• Familiarity with benefit plan documents, certificates of coverage, and benefit contracts, and plan riders
• Understanding of insurance carrier claims processing
• Knowledge of Durable Medical Equipment (DME) prescription procedures and plan riders
• Strong desire to provide outstanding customer service
• Ability to work as part of a team
• Ability to educate callers
• Strong listening skills and empathy
• Ability to ask open-ended questions and uncover information
• Effective communication skills to interact with members, physicians, and insurance carrier representatives
• Special ability in mediating or negotiating compromises without alienating any party
• Ability to calm anxious callers and defusing angry or hostile callers
• Assertive, self-confident, and resilient
• Attention to detail and strong documentation skills
• Proficient computer skills (Microsoft Office, Excel, Outlook, Adobe PDF, Internet Searches)

Click Here To Apply

Health Advocate is an Equal Opportunity Employer that does not discriminate on the basis of race, color, sex, age, religion, national origin, citizenship status, military service and veteran status, physical or mental disability, or any other factor not related to job requirements. We respect and value diversity, and are committed to the principles of Equal Employment Opportunity.

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