Claims Appeal Specialist

2 weeks ago

Lewiston, Maine, United States Community Health Options Full time
***Community Health Options' Claim Appeals Specialist reports is responsible for monitoring, processing, documenting, and meeting timely requirements for Community Health Option's Claim Appeals and Reconsiderations. Also ensuring and facilitating efficient and effective interdepartmental operations and communication with a primary focus on regulatory compliance, quality assurance and accuracy of claims, appeals, and reconsiderations.

RESPONSIBILITIES

  • Supports Manager in writing/reviewing Appeal letter language to ensure adherence to documentation requirements and timely processing in accordance with NCQA standards and State regulations.
  • Supports in processing appeals in accordance with established standards and workflow.
  • Generates reports, monitors and addresses trends identified within appeals and reconsiderations received.
  • Demonstrated attention to detail in ensuring timeliness, accuracy and completion of all documentation requirements related to denial and appeal letters and supporting documentation.
  • Maintains confidentiality in all aspects of Member, Health Options people, and company information.
  • Supports in development and enhancements to appeals platforms, workflows, and other related claims platforms and workflows.
  • Any other project work or supportive duties as assigned.

KEY COMPETENCIES:

People within Community Health Options are expected to work with integrity, humility, strategic vision, curiosity, and discipline.

They must be self-motivated, highly effective, and compassionate communicators, effectively working with people, work processes, and actively engaging in continuous process improvement.

Health Option diversity initiatives are applicable—but not limited—to our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of diversity equity, which encourages and enforces:

  • Respectful communication and cooperation between all employees.
  • Teamwork and employee participation, permitting the representation of all groups and employee perspectives.
  • Work/life balance through flexible work schedules to accommodate employees' varying needs.
  • Employer and employee contributions to the communities we serve to promote a greater understanding and respect for the diversity.

QUALIFICATIONS

  • Health Plan appeal experience, preferred.
  • High School Diploma or GED required
  • Strong working knowledge of medical terminology.
  • Able to work independently with mínimal supervision.
  • Demonstrates strong analytical thinking and problemsolving skills.
  • Exhibits precision and flexibility responding to competing priorities in a fastpaced environment.
  • Appreciation of cultural diversity and sensitivity towards individual preferences and needs of Member population.
  • Proficient in English with verbal, written, interpersonal and public communications.
  • Exhibits professionalism and delivers superb customer service through all interactions and correspondence.
  • Demonstrated attention to detail in ensuring timeliness, accuracy, and completion of all documentation requirements. Proficient with Microsoft Office products, typing, and ability to maintain accurate clinical documentation; ability to develop high quality reports for presentation to key internal/external stakeholders.
  • Ability to maintain production levels and quality standards with mínimal direct supervision.

REMOTE WORKERS:

This is a full-time remote position that will require the selected applicant to provide sufficient Internet bandwidth to meet system operational needs, and to have a home office environment that protects the privacy and integrity of confidential information.

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