Appeals Specialist II

Health Care Service Corporation; United States; Remote; USD 26,000 - 47,000; Full time

Job summary

HCSC is committed to empowering employees with development plans that foster growth and rewarding careers. This position handles complex non-utilization appeals under supervision, ensuring adherence to federal, state, and NCQA requirements.

The role may involve training and mentoring peers and communicating with members by multiple channels. Ideal candidates have a high school credential, 3 years in customer service or health insurance, knowledge of medical terminology, and strong written and

Qualifications

• High School Diploma or GED.
• 3 years’ experience in a customer service role OR in a health insurance or medical environment.
• Knowledge of medical terminology to include coding.
• Experience and skills to analyze and assist customer based on knowledge of federal, state, and NCQA guidelines.
• Experience and skills to organize tasks and accommodate large volume of reference materials.
• Experience and skills to understand fine details of customer complaint issues.
• Verbal and written communication skills.

Responsibilities

• Process and adjudicate complex non-utilization management appeals.
• Manage appeals according to applicable federal, state, and NCQA requirements and regulations.
• Respond to inquiries by phone, in person, or in writing related to member requests for appeals.
• Train and mentor less experienced appeals specialists.

Skills

Verbal communication

Written communication

Medical terminology

Education

High School Diploma or GED

Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Under Supervision, This Position Is Responsible For Processing And Adjudicating Complex Non-Utilization. Management Appeals According To The Appropriate Federal, State, And Ncqa Requirements And Regulations; And Responding, By Phone, In Person, Or In Writing, To All Inquiries Involving Member*S Requests For Appeals. May Train And Mentor Less Experienced Appeals Specialists.

JOB REQUIREMENTS

• High School Degree or GED.
• 3 years’ experience in a customer service role OR in a health insurance or medical environment.
• Knowledge of medical terminology to include coding.
• Experience and skills to analyze and assist customer based on knowledge of federal, state, and NCQA guidelines.
• Experience and skills to organize tasks and accommodate large volume of reference materials.
• Experience and skills to understand fine details of customer complaint issues.
• Verbal and written communication skills.

PREFERRED JOB REQUIREMENTS

• Claims experience.
• 2-year experience processing claims and utilizing a claims payment system.
• Bilingual English/Spanish.

Compensation: $19.13 - $34.17

Exact compensation may vary based on skills, experience, and location

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. We are a drug-free and smoke-free workplace. Employment may be contingent upon successful completion of drug screening in accordance with applicable law.