Appeal Specialist
Allied Benefit Systems, LLC, United States
Job Description
Job Title: Appeal Specialist
Department: Claim Operations
FLSA Status: Exempt
Job Status: FT
Reports To: Supervisor, Claim Operations
Positions Supervised: N/A
Assessments: Predictive Index Behavioral and Cognitive
Work Schedule: Virtual with flexible full-time hours
POSITION SUMMARY
The Appeals Specialist will be responsible for the organization and completion of all claim appeals received in the Appeal Department.
ESSENTIAL FUNCTIONS
- Logging/tracking all appeals received
- Reviewing appeal and supporting documentation
- Reviewing Summary Plan Documents to determine validity of appeal
- Composing appeal response letters when necessary
- Communicating with other departments and clients when necessary
- Documenting the QicLink system and database with appeal status and outcome
- Emailing claims examiners and other units when necessary
- Prioritize incoming referrals to complete all tasks timely
- Other duties as assigned
POSITION QUALIFICATIONS
Communication Communicates effectively both internally and externally, where applicable. Includes both written and verbal communication.
Customer Focused Works well with customers/clients both internal and external, promotes a positive image of the company and department, and strives to solve issues raised by customers.
Dependability Meets deadlines, works independently, accountable, maintains focus, punctual, and maintains good attendance record.
Initiative Takes action independently, seeks new opportunities, and strives to see projects to completion.
Interpersonal Skills Builds strong relationships, is flexible/adaptable, works well with others, and solicits feedback.
Job Knowledge Understands the facets of job, aware of duties and responsibilities, and keeps job knowledge current.
Organization Skills Information organized and accessible maintains efficient work space, and manages time well.
Problem Solving Strives to understand contributing factors, works to resolve complex situations.
Productivity Manages workload, works efficiently, and meets goals and objectives.
Self-Development Looks for opportunities to increase knowledge, works to increase responsibility, strives to achieve personal goals and/or maintains licenses and other pertinent requirements.
Sense of Urgency Meets deadlines, establishes appropriate priority, and completes tasks assigned in timely manner.
Teamwork Accountable to team, works to meet established deliverables, appreciates view of team members, and respectful.
Technical Skills Maintains current understanding of technical process/equipment, uses technology to increase performance/productivity; effectively uses online tools and resources.
EDUCATION
High School Diploma or Equivalent Required
EXPERIENCE
Applicants must have 3 years or more of comprehensive experience with the billing of or otherwise handling of medical, dental and vision claims. The applicant must have the ability to analyze claim situations, take appropriate actions and be great with communication and documentation. The applicant must have a history of excellent quality results and the desire to take on a new challenge if currently employed at Allied.
SKILLS amp; ABILITIES
Applicant should be proficient in the use of the Excel and Word programs, have experience with or ability to learn Microsoft Access and be able to communicate effectively both orally and by email.
CERTIFICATES amp; LICENSES
None
PHYSICAL DEMANDS
Sitting, working at a computer for long periods of time.
WORK ENVIRONMENT Flexible hours, ability to work from home upon tenure requirements and approval from manager.