Health Advocate Appeals Specialist
West Corporation

Job Info

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For this opening we will consider candidates from the following locations: PLYMOUTH MEETING,PA,US |

Are you looking for a meaningful job where the work you do truly makes a difference in people's lives every day?

Health Advocate is currently seeking an Appeals Specialist for our site in Plymouth Meeting, PA. Our next Appeals Specialist should have a great eye for detail, possess strong communication and negotiation skills, and have in-depth knowledge of healthcare insurance and the appeals process. Great organizational skills, a strong understanding of professional customer service, and the ability to form and maintain close working relationships with business partners are key to success in this role as well. If this sounds like you, then we would love to speak with you!

We offer great benefits! The benefits package for this position includes very generous Paid Time Off, paid holiday policy, tuition reimbursement and a 401(k) with a match. Health Advocate has an Employee Assistance Program, wellness programs and employee activities to support employees with various goals.

The Appeals Specialist is responsible for:

• Providing appeals assistance for members with denied medical treatment or services claims, which includes advocating for members in the appeals process

• Negotiating fees on behalf of the member

• Researching denied claims ensuring proper coding

• Educating members on the components of their benefit plan coverage

Additional job responsibilities include:

• Research billing issues to determine the possible cause of the error ensuring to assist with claims re-submission as required to correct the issue

• Establish and maintain a network of key contacts within insurance carriers, federal and state offices, and the health insurance industry

• Educate members on insurance plan provisions ensuring they have a full understanding of their plan

• Research and evaluate appeals issues to determine the possible cause of the error ensuring to assist the client throughout the appeal process

• Document all appeals issues thoroughly maintaining department files and appropriate databases

• Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels

Mental and Physical Requirements

• This position will be exposed mainly to an indoor office environment and will be expected to work near or around computers, telephones, and printers

• The nature of the work in this position is sedentary and the incumbent will be sitting most of the time

• Essential physical functions of the job include typing, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day

• Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day

Qualifications - Internal

Education

• High School Degree or GED required

• Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field preferred

Experience

• Minimum of five years, healthcare or carrier customer service, healthcare, appeals, or a related experience required

• Minimum 1-year claims experience preferred

Other

• Basic Knowledge of MS Word and Excel required

• Must score acceptably on job related testing

• Knowledge of the following is preferred:

• COBRA

• Medicare A, B, MediGap, Supplement plans, Medicare Advantage, Medicare Part D plans

• High deductible health plans including Health Reimbursement Accounts (HRAs) and Health Saving Accounts (HSAs)

• Flex Spending Accounts (FSA), including limited FSAs

• Coordination of benefits and which plan is primary - simple and complex cases (commercial plans, Medicare plans)

• Summary Plan Documents (SPDs) and Certificates of Coverage (COCs)

• Government programs, resources and legislation and mandates including but not limited to Affordable Care Act, FMLA, Medicaid, CHIP

• Group Health Plans (fully insured and self-insured)

• Pharmacy benefits including injectable medications

• Individual Health plans and Exchanges plans

• Strong communication skills and phone etiquette

This job has expired.