Appeals Representative (Remote)

Description

American Specialty Health, Inc. is seeking a detail-oriented Appeals Representative in our Appeals & Grievances team. This position will review and prepare all levels of provider and member appeals/grievances for consideration by the Review Committees. The ideal candidate will have strong oral and written communication skills and has the ability to remain professional and courteous.

Hourly Salary Range

American Specialty Health complies with state and federal wage and hour laws and compensation depends upon candidate’s qualifications, education, skill set, years of experience, and internal equity. $17.84 to $18.75 Hourly Wage Range.

Responsibilities

• Prepares appeals/grievances for review by the Review Committees.
• Reads each appeal/grievance to determine what is being requested and what action should be taken.
• Researches issue using all available resources as well as calling the provider or member.
• Prepares case in writing for review by Committee.
• Documents appeal in TOGA and CHIP.
• Sends appropriate response letter regarding appeal/grievance outcome.
• Prepares and sends appropriate non-compliance letters to non-compliant providers, including educational letters.
• Prepares cases for Administrative Appeals Committee review. Prepares cases for Administrative Review Committee agenda.
• Miscellaneous projects and reports as needed.
• Attends staff and other meetings to discuss issues and foster teamwork among department personnel.

Qualifications

• High School diploma required.
• Minimum two years of progressive experience performing customer service duties. Managed care or health care experience handling member and provider issues preferred. 
• Proficient in computer programs such as Word and Excel.

Core Competencies

• Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
• Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
• Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
• Ability to effectively organize, prioritize, multi-task and manage time.
• Demonstrated accuracy and productivity in a changing environment with constant interruptions.
• Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
• Ability to exercise strict confidentiality in all matters.

Mobility

Primarily sedentary, able to sit for long periods of time. 

Physical Requirements

Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in oral and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs.

Environmental Conditions

Work-from-home (WFH) environment.

American Specialty Health is an Equal Opportunity/Affirmative Action Employer.

All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth, related medical conditions, breastfeeding, and reproductive health decision-making), gender, gender identity, gender expression, race, color, religion (including religious dress and grooming practices), creed, national origin, citizenship, ancestry, physical or mental disability, legally-protected medical condition, marital status, age, sexual orientation, genetic information, military or veteran status, political affiliation, or any other basis protected by applicable local, federal or state law. 

Please view Equal Employment Opportunity Posters provided by OFCCP here.

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.

ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company’s legal duty to furnish information.

#LI-Remote #Appeals #Grievances #Claims Healthcare #Claims