Sr Appeals Specialist

Job Summary

The Sr Appeals Specialist investigates appeals and grievances in accordance with established policies and regulations. The Appeals Specialist is also responsible for the preparation of case files for both clinical and/or administrative review.

Responsibilities

•     Investigates Clinical appeal requests reviews the applicable medical policy/guidelines, member handbook, benefits, claims, pre-authorizations, and the corresponding medical records to identify the basis of the original decision and establish an understanding of the appeal/dispute.

•     Makes outreach calls to Members, Providers, and/or Member representative to acknowledge receipt of the appeal request.  Requests medical records necessary for the appeal review.

•     Prepares all case documentation (medical policy/guidelines, member handbook, Claims/Auth info, and medical records) and packages to submit for decision.  Documents entire investigation in the Appeals Management System.

•     Utilizes multiple Independent Review Organization (IRO) portals for submission of clinical appeals requiring matched-specialty review.  Coordinates with IROs on time-sensitive cases, and availability of particular specialties.  Reviews the IRO recommendation upon completion, and communicates back to the IRO with any questions or clarification needed. 

•     Creates appeal determination letters with a detailed description of the nature of the appeal, medical policy and benefits, the clinical rationale for the decision, and options moving forward.  Additional correspondence may also be sent throughout the Appeals process.  (automated letter process based off data entered in Appeals system)

•     Initiates effectuation (adjustment) request for overturned appeals and follows through until completion.

•     Regular contact with internal Medical Directors regarding appeal decisions, sign-offs, and input on complex clinical cases.

•     Regular contact with external vendors including Future Scripts, Magellan, AIM, etc. to obtain additional information, records, policy, and correspondence from the initial determination.  Coordinates effectuation process with vendor for overturned appeals.

•     Responsible for complying with timeliness and quality standards regulated by State & Federal entities, including Pennsylvania Insurance Department (PID) and NJ Department of Banking and Insurance (DOBI).  Additionally, adhere to policies and procedures set forth by the company, including contractual agreements with participating Providers.

•     Identifies trending appeal issues and initiates discussions across the Team and/or to Management for review and analyzation.  Provides input on possible process improvements.

•     In addition to processing Clinical cases, Senior Appeals Specialists may handle administrative Complaints, regarding payment and benefits appeals; reviewing benefits, claims, and coverage to verify the initial denial was correct. Educates member/member advocate on the coverage and benefit information and administers the appeal determination.  Creates and sends decision letter to the appellant.

•     Provides support to Triage and Appeals Specialists with questions on complex cases that potentially require medical review.

•     Provides Support to Clinical Appeals Coordinators (CACs) with administrative tasks during the appeal process.

•     Performs quality checks/reviews.

•     Performs other duties as assigned