Appeals Specialist - J29, Inc

Position Purpose:
Performs moderately complex (journey-level) appeals work. Researches and responds to inquiries from providers, suppliers, beneficiaries, health plans, or others involved in the appeals/dispute process. May conduct phone calls with appellants for the purpose of scheduling phone discussions with the company decision maker.  Works under moderate supervision, with moderate latitude for the use of initiative and independent judgement. 

Essential Responsibilities:

• Provides customer service and researches and responds to inquiries received by phone, fax, mail, or email timely and accurately.  
• Interprets requests and determines appropriate response or course of action to bring to resolution with minimal assistance. 
• Conducts research using online federal regulations, review Medicare and Medicaid policy and guidelines to complete an accurate and well-supported decision. 

• Screens receipts to determine the issue addressed in the correspondence and address timely which may involve forwarding cases to the appropriate person or entity timely.
• Logs receipts and enters into database.

• Trends receipts/issues and schedules coordination meetings as required.
• Prepares and sends professionally worded letters, emails or faxes.
• May initiate, schedule and coordinate reconsideration phone discussions between suppliers and decision makers by coordinating with appellants on schedule adherence and reschedule as needed, reviewing decision maker calendars to ensure phone discussions are held as scheduled with minimal interruptions, and validate additional documents submitted by appellant and that verbal testimonies are received and images are uploaded into appropriate system.

• Participates in special projects and performs other duties as assigned.

Minimum Qualifications

Education

• High School Diploma or equivalent

Experience

• Three (3) years of general office experience
  • College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.)
• One (1) year of  Medicare Qualified Independent Contractor appeals experience OROne (1) year of professional business writing experience in the healthcare, customer service or legal industries
• Experience directly relevant to the specific task order or project, preferred

Knowledge, Skills and Abilities

Working Knowledge of

• Research techniques
• Medicare appeals program
• Medical terminology
• Applicable systems and applications
• Applicable laws, rules and regulations

Proficient Skill in

• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
• Prioritizing and organizing work assignments
• The use of personal computers and applicable programs, applications and systems

Some Skill in

• Researching, analyzing and interpreting policies and state and federal laws and regulations

Ability to

• Meet production and quality standards
• Multitask and meet deadlines
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities

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