Strategic Healthcare Appeals Specialist

w3r Consulting; Illinois; Vor Ort; USD 70.000 - 100.000; Vollzeit

Zusammenfassung

w3r Consulting is seeking a dedicated Appeals Specialist to manage and resolve member and provider appeals within a regulated healthcare environment. You will ensure timely resolutions, maintain thorough documentation, and collaborate across UM, CM, and CS teams.

The role requires strong communication, organizational, and multitasking skills, with a focus on HIPAA, NCQA, URAC, and regulatory compliance. Illinois-based operations emphasize accuracy and audit readiness.

Qualifikationen

• Bachelor's degree or 4 years of healthcare experience.
• 5 years of experience in Utilization Management, appeals, claims, and mainframe systems.
• Knowledge of managed care, healthcare operations, and regulatory requirements.
• Strong communication, organizational, and multitasking skills.
• Proficiency in Microsoft Word, Excel, and Access.

Aufgaben

• Manage assigned appeal inventory and ensure timely resolution.
• Review and resolve member and provider appeals.
• Collaborate with Utilization Management (UM), Case Management (CM), and Customer Service (CS).
• Communicate with members and providers regarding appeal outcomes.
• Maintain accurate documentation, reporting, and audit readiness.
• Ensure compliance with HIPAA, NCQA, URAC, and state and federal regulations.

Kenntnisse

Strong communication

Organizational skills

Multitasking

Regulatory understanding

Ausbildung

Bachelor's degree / 4 years healthcare experience

Tools

Microsoft Word

Microsoft Excel

Access

Jobbeschreibung

w3r Consulting is seeking a dedicated Appeals Specialist to manage and resolve member and provider appeals within a regulated healthcare environment. You will ensure timely resolutions, maintain thorough documentation, and collaborate across UM, CM, and CS teams.

The role requires strong communication, organizational, and multitasking skills, with a focus on HIPAA, NCQA, URAC, and regulatory compliance. Illinois-based operations emphasize accuracy and audit readiness.