Appeals Specialist , II or III

About The Company

PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah’s public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.

For most jobs, remote work is available for 9 out of every 10 workdays.

This position is available at three levels. Candidates will be considered for the level that best matches their qualifications and experience.

Appeals Specialist I- Min: $18.10/hr max: $22.64/hr.

Appeals Specialist II- Min: $19.73/hr max: $24.67/hr.

Appeals Specialist III- Min: $21.52/hr max: $26.90/hr.

The Appeals Specialist plays a critical role ensuring that PEHP member and provider appeals are researched according to Master and Corporate Policy and compiling appeal documentation for review by the PEHP Executive Review Committee and the PEHP Provider Dispute Review Committee. This role performs a variety of reviews for medical, dental, FSAs, and enrollment appeals that have been disputed by members or providers.

Successful performance requires knowledge of PEHP policies and various group plan benefits. Fundamental skills include strong letter writing and communication skills, conflict management experience, analysis, and the ability to be a team player.

• Researches requests for review of resolvable claims from providers. Compiles information related to member appeals that request an Executive Review.
• Provides copies of necessary documents and submits information to the Appeals and Policy Manager for review. Copies appropriate documents from appeal file, creates information packets, and distributes to members of the Executive Review Committee prior to scheduled meetings. Maintains current data on appeals and resolvable claims.
• Meets with members to coordinate the review of claim payment documents and records that pertain to the appealed claim. Provides copies of such claim’s payment documents and records to members upon request.
• Ensures compliance with state and federal regulations and provider contracts throughout all levels of the appeals process.
• Ensures that denied claims that are approved on appeal are paid promptly and correctly according to the directives of the Executive Review Committee.
• Creates written correspondence to members and providers regarding appeal outcome and benefit determination. Creates written documentation of Executive Review Committee decisions. Documents approval or denial of appeal in the members’ history and in the Case Data Management log.
• Maintains files and documentation relating to the development, updating, and maintenance of the Master Policy and other applicable documents (i.e., Benefit Summaries, Comparison of Benefits, etc.). Submits requests for benefit changes, wording changes, distribution, etc. to the Appeals and Policy Manager. Documents approval and makes certain that the approved changes/modifications are made to all applicable documents. Ensures that changes are communicated to all employees involved in processing resolvable claims and appeals.
• Participates in researching correct coding for specific medical, dental, and pharmacy payment policies and procedures created by Clinical Management. Provides updated information for maintenance to claims payment editing systems.
• Maintains various reports needed to track departmental functions and productivity.
• Is responsible for some imaging tasks.
• Receives referrals from adjuster/customer service, providers, insured members, through screening of claims histories and system automation. Works closely with providers, vendors, and insured members to obtain information including but not limited to history and physicals, treatment plans, progress notes, pre-authorization requests, etc.
• Maintains strict confidentiality.
• Performs other duties as required.