Appeals may be submitted by providers and their representatives, members, attorneys, and occasionally a Preferred Provider Organization (PPO) requesting a review. This role involves researching both internal and external appeals related to benefit determinations, UsualCustomary reductions, discount disputes, and eligibility issues. The position requires collaboration with internal review vendors for internal appeals and Independent Review Organizations (IROs) for external reviews - an essential team process that must be conducted on-site. You’ll work closely with clients, the reinsurance and subrogation departments, case management and precertification vendors, and occasionally PPOs. Responsibilities include drafting clear, professional response letters to providers, members, representatives, and attorneys as needed, along with maintaining regular communication via phone and email with claims processors, reinsurers, vendors, providers, members, clients, and attorneys. It’s essential to ensure all appeals meet plan timeframes and regulatory guidelines. As with any role, additional tasks may be assigned as necessary to support the team and the appeals process.
The ideal candidate will possess a High School Diploma or GED, with some college coursework considered beneficial. Proficiency in Microsoft Word, Excel, and Outlook is essential for success in this role. Strong mathematical and analytical skills, paired with exceptional attention to detail and the ability to meet critical deadlines, are required. The candidate must demonstrate professional phone communication skills and excellent organizational and customer service abilities. Strong writing skills are crucial, including proper grammar, punctuation, and sentence structure. Effective problem-solving and decision-making capabilities are vital, and the candidate should be self-motivated with a proactive approach to learning and adapting. Reliable attendance and a dedication to supporting team goals are key to thriving in this position.

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