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Appeals Specialist I in Oak Brook, IL at VisionPRO

Date Posted: 7/19/2018

Job Snapshot

Job Description

Appeals Specialist I – Job 72345


  • Manages submission, intervention and resolution of appeals, grievances, and/or complaints, from Company's members and related outside agencies, as a part of the integrated Healthcare Services Team
  • Conducts pertinent research, evaluates, responds, and completes appeals and other inquiries accurately, timely, and in accordance with all established regulatory guidelines
  • Prepares appeal summaries and correspondence and documents information, for tracking/trending data

Essential Functions:

  • Enters denials and requests for appeal into information system, and prepares documentation for further review
  • Researches issues, utilizing systems and clinical assessment skills, knowledge, and approved Decision Support Tools, in the decision-making process, regarding healthcare services and care provided to members
  • Assures timeliness and appropriateness of all Provider appeals, according to state, federal, and Company Healthcare guidelines
  • Requests and obtains medical records, notes, and/or detailed bills, as appropriate to assist with research
  • Evaluates for medical necessity and appropriate levels of care, and formulates conclusions, per protocol
  • Collaborates with Medical Directors and other team members, to determine appropriate responses
  • Obtains Medical Director approval for determination, per Company protocol
  • Works with Customer Service, to resolve balance bill issues, and other member complaints regarding providers
  • Prepares responses to provider grievances / appeals
  • Elevates appeals to the appropriate committee and/or manager, per protocol
  • Prepares and assists in the preparation of the narratives, graphs, flowcharts, etc., to be utilized for presentations and audits
  • Coordinates workflow between departments, and interfaces with internal and external resources
  • Receives and resolves provider inquiries related to claims
  • Acts as a liaison between the providers and health plan, as appropriate
  • Assists with interdepartmental issues, to help coordinate problem-solving, in an efficient and timely manner
  • Identifies and refers cases appropriately, for Health Management, Case Management, Quality Improvement, and Health Education, per established triggers
  • Documents referrals, according to Company Healthcare process
  • Creates and/or maintains statistics and reporting


  • Comprehensive knowledge of healthcare customer service, regulatory requirements, and Provider Dispute and/or Member Appeal process
  • Knowledge of CPT/HCPC and ICD9 coding, procedures, and guidelines
  • Comprehensive clinical decision logic and analysis skills
  • Excellent vocabulary, grammar, spelling, punctuation, and composition skills, proven through the development of written communication
  • Maintains regular attendance, based on agreed-upon schedule
  • Computer skills, and experience with Microsoft Office Products
  • Excellent verbal and written communication skills
  • Ability to abide by Company policies
  • Maintains confidentiality and complies with Health Insurance Portability and Accountability Act (HIPAA), and fraud and abuse prevention detection policies and procedures
  • Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers

Required Experience:

  • 1-2 years of Utilization Review experience and Managed Care experience
  • Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for 
  • Must have experience with claims research and analysis
  • Must be able to understand how to analyze why a claim didn't pay, using critical thinking skills
  • Candidates need to be critical thinkers, decision makers, reliable, and timely
  • Experience with claims; e.g., 1500 and UB, needed

VisionPRO relentlessly delivers top talent to help our clients excel. We have been trusted for 20 years to align the right talent to the right opportunity, expertly solving unique business challenges. From small businesses to the Fortune 500, our clients appreciate our consultative approach, resourcefulness, and fast response to their individual needs. Our prospective candidates and existing consultants can count on VisionPRO to passionately help them maximize their career choices, while also supporting their growth opportunities. We serve our customers from around the world, helping them with their most critical hiring decisions and project needs.