Appeals Review Specialist

Imagine360; United States; Remoto; USD 45.000 - 65.000; Tempo pieno

Vantaggi offerti da questo lavoro

Multiple Health Plan Options

Company paid employee premiums for dis

Life Insurance

Parental Leave Policy

20 days PTO to start / 10 Paid Holiday

Tuition reimbursement

401k Company contribution

Professional development initiatives

Diversity & inclusion initiatives

Descrizione del lavoro

Imagine360 is seeking an Appeals Review Specialist to join our remote team. The role focuses on reviewing claims for errors, addressing provider inquiries, and generating denial explanations while maintaining strict confidentiality.

Responsibilities include researching questions, training staff, and contributing to quality improvement efforts to protect plan assets and ensure compliance with plan documents.

Competenze

• Proficient in office software and data entry accuracy.
• Experience reviewing healthcare claims and supporting denials/appeals.
• Ability to maintain confidentiality and follow regulatory guidelines.

Mansioni

• Review claims for accuracy against medical records.
• Respond to member/provider inquiries in writing or by phone.
• Provide denial explanations and escalation as needed.
• Support training and quality improvement initiatives.

Conoscenze

Microsoft Office

10-key typing

Attention to detail

Communication skills

Confidentiality

Formazione

High school diploma or equivalent

Minimum of two years healthcare claims experience

Strumenti

Microsoft Office

Descrizione del lavoro

Imagine360 is currently seeking an Appeals Review Specialist to join our team! The Appeals Review Specialist is responsible for the review of claims from providers for possible errors to ensure plan assets are protected. This position maintains a comprehensive understanding of the plan document(s) under their scope of responsibility

Position: 100% Remote

Responsibilities include but are not limited to:

• Claim edits and reviews
  • Verifies claim accuracy compared to medical record.
  • Reviews claims edit for fraud and abuse.
  • Escalates claims to Utilization Management Vendor when appropriate.
• Appeals/Inquiries
  • Reviews, researches, and responds to members and providers in writing regarding questions, complaints or denied coverage objections.
  • Provides denial explanations.
  • Responds in writing and/or via phone to all inquiries in an accurate and timely manner.
  • Trains claims employees to improve quality for reviews and appeals.
• Customer Service - Internal/External
  • Acts as a role model in demonstrating the core values in customer service delivery.
  • Provides timely and thorough follow up with, internal and external customers.
  • Sends letters to providers and members explaining a denial.
  • Appropriately escalates difficult issues up the chain of command.
• Quality Assurance
  • Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.
  • Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.
  • Performs self quality monitoring in order to develop and execute plans to meet established goals.
  • Provides ongoing feedback to help optimize quality performance.
  • Collaborates with others and cross-departmentally to improve or streamline procedures.
  • Develops new or improves current internal processes to improve quality.
• Compliance
  • Maintains regulatory compliance standards

Education and Experience:

• High school diploma or equivalent
• Minimum of two years experience in healthcare claims examining or related work experience

Skills and Abilities:

• Working knowledge of computers and software including but not limited to Microsoft Office products
• Proficient 10-key and typing skills
• Demonstrated self-motivation, organizational skills, problem-solving skills
• Strong written and oral communication skills with attention to detail and accuracy
• Demonstrated ability to remain neutral and maintain confidentiality.

What can Imagine360 offer you?

• Multiple Health Plan Options
• Company paid employee premiums for disability, and Life Insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.