Appeals Representative (Remote)

Job Description:

Description

American Specialty Health Incorporated 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 RangeAmerican 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 $18.50 Hourly Wage Range.Remote Worker ConsiderationsCandidates who are selected for this position will be trained remotely and must be able to work from home (WFH) in a designated work area with company-provided technology equipment. This remote/WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network (minimum internet download of 50 Mbps and 10 Mbps upload speed).

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 or GED 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.