Claims Appeals Specialist

JOB DESCRIPTION

JOB SUMMARY

The Claims Appeals Specialist is responsible for managing and processing appeals related to insurance claims.

This role involves reviewing denied claims, analyzing documentation, and ensuring compliance with regulatory standards, including the Employee Retirement Income Security Act (ERISA) of 1974.

The specialist will work closely with insurance claimants, healthcare providers, Claims, and Legal & Compliance teams to resolve disputes and ensure fair outcomes.

RESPONSIBILITIES


* Review and analyze claim decisions to determine the validity of the denial, including status and within timeframe expectation.


* Prepare and submit appeal letters and documentation for review.


* Communicate with Claims, healthcare providers, and claimants to gather necessary information and clarify details.


* Maintain detailed records of appeals and outcomes in the claims management system.


* Ensure compliance with all relevant regulations, policies, and procedures.


* Monitor appeal deadlines and ensure timely submission of all required documentation.


* Collaborate with other departments to resolve complex claim issues.


* Provide feedback and recommendations for process improvements to reduce claim denials.


* Stay updated on changes in insurance regulations and industry best practices.


* Assist in training and mentoring new team members as needed.


* Support compliance needs and risk audits as needed.


* Assist with incorporation of Compliance's interpretation of regulations and laws into Claims processes in a user-friendly way.


* Perform other duties as assigned.

COMPETENCIES


* Problem Solving: Takes an organized and logical approach to thinking through problems and complex issues.Simplifies complexity by breaking down issues into manageable parts.

Looks beyond the obvious to get at root causes.

Develops insight into problems, issues and situation.


* Continuous Learning: Demonstrates a desire and capacity to expand expertise, develop new skills and grow professionally.Seeks and takes ownership of opportunities to learn, acquire new knowledge and deepen technical expertise.

Takes advantage of formal and informal developmental opportunities.

Takes on challenging work assignments that lead to professional growth


* Initiative: Willingly does more than is required or expected in the job.Meets objectives on time with minimal supervision.Eager and willing to go the extra mile in terms of time and effort.

Is self-motivated and seizes opportunities to make a difference.


* Adaptability: Ability to re-direct personal efforts in response to changing circumstances.

Is receptive to new ideas and new ways of doing things.

Effectively prioritizes according to competing demands and shifting objectives.

Can navigate through uncertainty and knows when to change course


* Results Orientation: Effectively executes on plans, drives for results and takes accountability for ...