Appeals Specialist III at Three Point Solutions Inc

Job Title: Appeals Specialist III / Member Service Rep III

Client: Health Care Insurance

Duration: 4 Months

Location: Baltimore, MD 21224 (Mandatory- 100% remote however the resource must reside in District of Columbia, Maryland, Virginia(DMV)

Job Title: Appeals Specialist III

Responsibilities:

• Assist Manager, Supervisors, and Business Analysts with projects, quality audits, and operations
• Analyze appeals correspondence, determine next steps, and expedite processing
• Serve as subject matter expert, providing coverage for complex cases
• Prioritize, research, and analyze information for initial inquiries
• Lead a team in identifying risks and trends in processes
• Research high-profile cases and communicate with governmental agencies
• Develop accurate professional written communications and verbal interactions
• Present and discuss compliance issues, providing recommendations
• Research contractual benefits, limitations, and exclusions
• Assist medical staff with appeals and reconsiderations
• Act as liaison for time-sensitive or escalated tasks
• Provide training and mentorship to entry-level associates
• Design and deliver training programs for internal customers
• Support committees and special projects

Top 5 Required Skills:

1. MD Medicaid appeal and grievance experience in managed care
2. Data entry skills
3. Organizational skills
4. Medical terminology
5. Knowledge of systems (Hyland OnBase, Health Rules, Care Manager)

Qualifications:

• Education Level: High School Diploma
• Experience:
  • 5 years in managed care, health care, or insurance payor environment
  • 3 years in Clinical Appeals and Analysis Unit
  • 2 years as Appeals Specialist II

Preferred Qualifications:

• College Degree
• Knowledge of client systems, Member/Provider Service, Claims, or Care Management
• Leadership experience