Appeal Resolution Specialist logs, tracks, and processes appeals and grievances. Sets up and maintains case files for each grievance and collects the information required by organizational policies and applicable regulations. Being an Appeal Resolution Specialist conducts research and coordination needed to evaluate, process, respond to, and refer or close appeals. May require an associate degree or equivalent. Additionally, Appeal Resolution Specialist typically reports to a supervisor. The Appeal Resolution Specialist works under moderate supervision. Gaining or has attained full proficiency in a specific area of discipline. To be an Appeal Resolution Specialist typically requires 1-3 years of related experience. (Copyright 2024 Salary.com)
It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
Job Summary:
This position is responsible for accurate and timely research of all claim dispute inquiries, timely processing of adjustments and acts as a claims liaison between internal and external partners and helping with other Claims-related initiatives. Responsible for the accurate and timely processing of internal inquiries to the Claims Resolution team. Must complete duties with a high level of detailed quality and professionalism.
Our Investment in You:
* Full-time remote work
* Competitive salaries
* Excellent benefits
Key Functions/Responsibilities:
* Performs review of previously processed claims coming into the CRU to determine if additional information is required or if the documentation present is sufficient to determine if claim requires reprocessing.
* As part of claim review process use multiple systems to confirm claims were processed accurately based on contracts, medical policy and other policies and procedures, review accumulators and calculations of deductibles and maximums as applicable.
* Investigate and perform adjustments of complex claims.
* Determines root cause of claim processing errors and reports findings to leadership for further investigation and to prevent future errors.
* Provides verbal or written responses to inquiries from internal business areas. Appropriately documents all interactions according to established department procedures.
* Ensures data is entered into the appropriate case tracking system to ensure all pertinent information is recorded for internal tracking and monitoring.
* Provides feedback on opportunities found during review for remedial training.
* Serves as the subject matter expert for the team.
* Manages complex claims projects / large volumes of adjustment requests.
* Will present data and analysis within regular work group meetings.
* Maintain timely resolution of inquiries according to established timeframes.
* During peak claim volumes, may provide back-up on an as needed basis to the Claims Department
* Other duties as assigned
Supervision Exercised:
Supervision Received:
Qualifications:
Education Required:
Education Preferred:
Experience Required:
Experience Preferred/Desirable:
Required Licensure, Certification or Conditions of Employment:
Competencies, Skills, and Attributes:
Working Conditions and Physical Effort:
Telecommuting Requirements
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
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