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Health Plan Claims Appeal Specialist
2 months ago
Overview:
As the Health Plan Claims Appeal Specialist for a Health Maintenance Organization (HMO), and other Health Plans based in Texas, this position is responsible for investigating and resolving all first level and second level Health Plan Claims Appeals. In reviewing the Claims Appeals, this role is responsible for assessing the appeals to ensure accuracy, compliance with regulations, adjudication is accurate and adherence to company policies is precise.
Responsibilities:Essential Functions
Conducts reviews of 1st Level Claims Appeals and coordinates with Claims Manager for resolution.
Conducts reviews of 2nd Level Appeals and coordinates with designated Executive Team for resolution.
Coordinates Claims Appeal adjudication adjustments with Claims Manager.
Provides feedback and recommendations to Claims Manager and designated Executive Team for policy changes to reduce Claims Appeals.
Collaborates with network providers and the Health Plan Network Team to resolve Appeals and trends.
Assists Claims Team with measures to reduce claims adjudication processes that impact Appeal submissions.
Prepares periodic historic Claims Appeal reports for Claims Manager and designated Executive Team.
Performs other duties as assigned.
EDUCATION:
- High School Diploma required.
- Bachelor's Degree in Healthcare Administration, Business Management, or related field preferred.
EXPERIENCE:
- 3 years Claims Adjudication, Auditing or Appeals Review
