Appeals Specialist

Job description

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 ag...