AppealsSpecialist

The Appeals & Grievances (A&G) unit processes member and non-contracted provider appeals for all of HF’s line of businesses which include commercial, Medicaid, dual enrollments, Medicare and complete care. Appeals Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. They manage their own caseload and is accountable for investigating and resolving member or non-contracted provider-initiated cases. **Key Responsibilities** * Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals. The end-to-end process requires the Specialist to independently: * Research issues * Reference and understand HF’s internal health plans’ policies and procedures to frame decisions * Interpret regulations * Resolve cases and make critical decisions * Edit and finalize resolution letters * Manage all duties within regulatory timeframes * Communicate effectively to hand-off or pick-up work from colleagues * Work within a framework that measures productivity and quality for each Specialist against expectations * Work independently exercising judgment starting the case development with the respective internal and external entities in the timeframe prescribed in the Job Aid and/or regulatory timeframes. * Prepare and submit well documented appeals in accordance with payer guidelines and within timely filing limits * Identify patterns or trends in denials and provide feedback for leadership for process improvement. * Remain up to date on payer polices, industry regulations and coding updates to ensure compliance and maximize reimbursement * Additional duties as assigned * **Minimum Qualification** * HS Diploma or GED from an accredited institution * Minimum of two (2) years of work experience in Managed Care Health Insurance Plan * Experience with appeals for Medicare, Medicai