Appeals Specialist - Remote

The Appeals & Grievances (A&G) unit processes member and non-contracted provider appeals for all of HF's line of businesses which include commercial, Medicaid, dual enrollments, Medicare and complete care. Appeals Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. They manage their own caseload and is accountable for investigating and resolving member or non-contracted provider-initiated cases.

• Responsible for case development and resolution of non-clinical cases, such as certain types of claim denials, member complaints, and member and provider appeals.
• The end-to-end process requires the Specialist to independently:
  Research issues, Reference and understand HF's internal health plans' policies and procedures to frame decisions, Interpret regulations, Resolve cases and make critical decisions, Edit and finalize resolution letters, Manage all duties within regulatory time frames, Communicate effectively to hand-off or pick-up work from colleagues, Work within a framework that measures productivity and quality for each Specialist against expectations, Work independently exercising judgment starting the case development with the respective internal and external entities in the timeframe prescribed in the Job Aid and/or regulatory time frames.
• Prepare and submit well documented appeals in accordance with payer guidelines and within timely filing limits.
• Identify patterns or trends in denials and provide feedback for leadership for process improvement.
• Remain up to date on payer polices, industry regulations and coding updates to ensure compliance and maximize reimbursement.
• Additional duties as assigned.

• HS Diploma or GED from an accredited institution
• Minimum of two (2) years of work experience in Managed Care Health Insurance Plan
• Experience with appeals for Medicare, Medicaid, Dual enrollment and commercial Plans end to end.
• Claims processing experience with coding criteria is preferred. This includes the auto forwarding of upheld cases to the respective regulatory independent reviewer for denied cases.

• Bachelor's degree from an accredited institution or relevant work experience
• Demonstrated critical thinking and decision-making competencies
• Demonstrated ability to be detail oriented, work under pressure, manage tight time frames

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis.

HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers or calling . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying.

Only reasonable accommodation requests related to applying for a position within HF…