Appeals Specialist

Position Code: 345

Department:  Appeals Management
Location: Little Rock, Arkansas
Immediate Supervisor:  Dan Honey
Status: Non-Exempt
Posted: July 07 2017

Essential Functions of Job:

• Review patient files and utilize knowledge and skills as well as knowledge of payer requirements to determine if medical or dental claim is adjudicated correctly. • Proficiently read and understand information from patient medical records, claims history and DOL/State regulations. • Processing of medical and dental claims. • Re-Price medical claims using PPO Network’s on-line systems/tools • Utilize criteria and other resources and clinical evidence to develop sound and well-supported documentation for review decisions • Coordinate drafting and mailing of letters related to member appeals • Prepare feedback and participate in meetings • Obtaining information by telephone as well as by hard copy and entering into the computer systems • Prioritization of individual work flow associated with the case assignments • Establishing and maintaining professional rapport with clients and providers (physicians and hospitals) • Maintaining and assuring accuracy of documentation • Meet and/or discuss with members, clients and providers the issues relating to claim administration • Ability to report to the office

Qualifications:

• High school diploma or equivalent • Effective organizational and prioritization skills • Excellent oral and written communication skills • Basic knowledge of Microsoft Office software applications (Word, Excel, Outlook, Access) • Ability to work in a fast paced multi-tasking environment • Strong interpersonal skills with ability to function as a positive team member • Superior skills in benefits interpretation is a plus • Strong mathematical background • 2-3 years experience in processing medical, dental and/or vision claims preferred

 

The Company considers applicants without regard to race, color, national origin, sex, religion, mental or physical disability, marital status, age 40 years and over, sexual orientation or gender identity, veteran's status, or other characteristic protected by applicable law.

Applications for this vacancy will be received for 3 working days after the Posted date from Employees of HealthSCOPE Benefits with more than one year of service.

Applications for this vacancy will be received for 10 working days after the Posted date from External Applicants.