Current Job Openings Job Title: Appeals Representative II
Job #: HSM068
Reports to: Manager, Quality Management
Department: HSM, Quality Management
Pay Status: Hourly
Exempt Status: Non Exempt
Full-Time: M-F 8:30am – 5:00pm
Summary of Responsibilities
Reviews, processes, submits, and tracks all types including expedited appeals/grievances. Communicates to departments responsible for implementing determinations.
1. Investigates, prepares, and files all types, including expedited appeal/grievances appropriately and consistently, within designated timeframes.
2. Researches customers appeal/denial situations submitted in both phone interactions and in written communications.
3. Prepares appeals/grievances files for review by Medical Directors, the Appeals Coordinator, or the Appeals Committee.
4. Writes appeal/grievance resolution letters to members, providers, and other appealing parties within defined time-frames and formant.
5. Processes, logs and files appeals and grievances in an organized and consistent manner.
6. Communicates appeal/grievance decisions to departments responsible for implementing determinations; ensures decisions are implemented correctly.
7. Communicates with members and providers while resolving appeals/grievances.
8. Assists in tracking and trending appeal/grievance activity.
9. Prepares documents for and records minutes of Appeals Committee meetings.
10. Assists Appeals Coordinator as needed.
11. Performs all job functions with integrity. Provides timely internal and external customer service in cooperative, professional, and respectful manner.
High school diploma/GED or may substitute with 1 year of like experience.
3+ years performing same or similar responsibilities. Relevant experience includes either: claims processing or member services experience in a managed care environment; or 2) office administration support to include servicing of internal/external customers and demonstrated ability to effectively write a variety of business correspondence; or 3) minimum of 6 months entry level appeals experience.
Required Licenses and/or Certificates:
Software and Data Entry Requirement:
1. Word at a basic level.
2. Excel at a basic level.