Appeals Representative

Duration: __03__ Months/__0 weeks.

• Receive, investigate and triage expedited appeal requests received from members/member representatives enrolled in Senior Products. Timely assignment of cases is critical to ensure member's appeal rights are processed in accordance with regulatory agencies' standards, including the Center for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA).

Position will involve:

• claims research and processing (more of researching why the claim was denied than actually research into the claim).
• processing appeals in the system.
• authorization lookups.
• Processing health insurance claims.
• At least 1 year of experience in health insurance claims and appeals is required.
• At least a HS degree, but a college degree and/or extensive experience would be considered.
• Outbound call experience (though not a large part of this job) is a good to have.
• A customer service background and experience, not necessarily in the healthcare field, is nice to have as well.
• Medicaid experience desired and will make the candidate stand out.