Event Specialist
Acosta
Appeals Analyst – GP
NJM Insurance Group
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $62,100 - $83,160 per year
Job Level
SeniorLead
About the role
- Participates/presents case findings at the Leadership Appeals Workgroup hearings and mentors junior staff. Appears before Leadership Appeals Workgroup to present cases, explain denials and address questions. Contacts company areas to facilitate fact gathering and understand benefit contracts; may consult with outside attorneys or DOBI and may testify. Authorizes administrative exceptions and conducts daily image queue review; conducts root cause analysis and recommends training to reduce appeals. Works with Quality/Training to develop and deliver refresher training workshops; represents Complaints/Appeals function on work groups; assists new staff mentoring and reporting.
Requirements
- High School Diploma/GED required. In lieu of degree applicant must have 5 years of equivalent and relevant work experience. Requires seven years of business experience which must include four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries. Healthcare industry experience required. Experience in complex claims processing necessary. Prior appeals handling experience preferred. Experience with NASCO and NCOMPASS preferred. Knowledge of HBCBSNJ complaints and appeals process preferred. Knowledge of insurance claim and membership systems required. Knowledge of medical terminology, COB, Medicare procedures required. Knowledge of UCSW preferred. Knowledge of Claims Policy guidelines required. Knowledge of Microsoft Office Suite required. Keyboarding proficiency. Ability to understand and use language correctly. Basic arithmetical calculations. Read, understand and interpret written materials. Analyze information and apply rules and procedures. Compose business letters. Strong verbal and written communication. Detail member/provider-specific issues through individual correspondence. Excellent interpersonal skills (active listening). Strong research, investigative, analytical and problem solving skills. Ability to multitask and manage irate callers. Time management skills.
