Appeals Specialist

Why is Health Advocate a great place to work? For starters, Health Advocate employees enjoy helping people every single day. Employees are given the training they need to do their jobs well, and they work with supervisors and staff who are supportive and friendly. Employees have room to grow, and many of Health Advocate's supervisors are promoted from within the company.  Join our award winning team!

2024:

• Excellence in Customer Service Awards: Organization of the Year (Small)

• Stevie® Awards for Sales & Customer Service: Customer Service Department of the Year – Healthcare, Pharmaceuticals, and Related Industries, Bronze Winner

As part of Teleperformance in the US, we were also named #95 in the 2024 ‘Fortune 100 Best Companies to Work For®’ in the USA by Great Places to Work (GPTW®)

Position Overview
The Appeals Specialist assists clients, members, and prospects with health insurance appeals. Analyze and research denied medical claims and lead efforts to resolve claims issues on behalf of the member. Process appeals within federally mandated timeframes. Escalate claims with managerial levels of insurance carriers or group administrators through key contacts.
The Appeals Specialist will be able to handle complex issues with minimal supervision. Establish and maintain key contacts with insurance carriers, negotiate fees on behalf of Health Advocate members, and appeal denied claims through the appropriate channels.
The Appeals Specialist will be in regular contact with insurance carrier key management, federal and state regulatory offices, members, Human Resource Departments, key clients, and physician office managers.
Essential Job Functions
• Achieve/exceed Call Center Metrics (ASA - 30 seconds; Abandon Rate 5%)
• Identify target resolution for all member calls and then, if possible, ensure cases close at or near the target resolution
• Inform members of your plan of action, expected results, and timeframes, then meet or exceed those timeframes
• Build confidence in our services to encourage members to call back with future questions
• Allay member anxiety and frustration
• Add value to our services by going beyond the member’s initial request
• Advocate for the member to receive coverage for the appropriate medical procedures, medications, and inpatient/outpatient treatment
• Establish and maintain a network of key contacts within insurance carriers, federal and state offices, and the health insurance industry
• Escalate members’ unpaid claims through key contacts
• Assist members in appealing denied claims verbally or in writing when appropriate, including preparing the member for oral appeals hearings
• Lead appeals process within federally mandated timeframes in cases where the member’s attempts have failed
• Serve as subject matter expert in the interpretation of health insurance plan language and state and federal regulation
• Negotiate fees on behalf of the member including facilitating communication between the member and the billing agent
• Research denied claims and verify proper coding
• Education members on their insurance plan provisions
• Assist internal staff in complicated claims related cases
• Document all cases in case management system using the SOAP method (Subjective, Objective, Assessment, Plan) when appropriate
Requirements
• Five or more years’ experience in health benefits or health insurance appeals preferred
• Understanding of health plan authorizations, including medical policy and claims payment guidelines to evaluate if appeals require clinical or administrative review
• Knowledge of applicable law and resources regarding confidentiality of privileged patient information and appeals administration
• Knowledge of procedure and diagnosis coding (ICD-9, HCPCS, and CPT-4)
• Familiarity with various types of health insurance coverage, coordination of benefits, and UCR fees
• Experience in reviewing, interpreting, and researching Explanation of Benefits (EOB’s) and denial letters
• Experience in identifying contractual appeal timeframes
• Familiarity with benefit plan documents, certificates of coverage, and benefit contracts, and plan riders
• Understanding of insurance carrier claims processing
• Knowledge of Durable Medical Equipment (DME) prescription procedures and plan riders
• Strong desire to provide outstanding customer service
• Ability to work as part of a team
• Ability to educate callers
• Strong listening skills and empathy
• Ability to ask open-ended questions and uncover information
• Effective communication skills to interact with members, physicians, and insurance carrier representatives
• Special ability in mediating or negotiating compromises without alienating any party
• Ability to calm anxious callers and defusing angry or hostile callers
• Assertive, self-confident, and resilient
• Attention to detail and strong documentation skills
• Proficient computer skills (Microsoft Office, Excel, Outlook, Adobe PDF, Internet Searches)

Company Overview

Health Advocate is the nation’s leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained, compassionate experts work together to go above and beyond expectations, making healthcare easier for our members and ensuring they get the care they need.

Learn more

Health Advocate https://www.healthadvocate.com/site/

Facebook https://www.facebook.com/healthadvocateinc/

Video https://vimeo.com/386733264/eb447da080

Awards:

2023:

• National Customer Service Association All-Stars Award: Service Organization of the Year.
• Stevie® Awards for Sales & Customer Service: Customer Service Department of the Year – Healthcare, Pharmaceuticals, and Related Industries, Bronze Winner

2022:

• Stevie® Awards for Sales & Customer Service: Customer Service Department of the Year – Healthcare, Pharmaceuticals, and Related Industries, Bronze Winner
• Excellence in Customer Service Awards: Organization of the Year (Small)
• Best in Biz Awards: Most Customer-Friendly Company of the Year – Medium and large category (Silver)

2021:

• Stevie® Awards for Sales & Customer Service: Customer Service Department of the Year – Healthcare, Pharmaceuticals, and Related Industries, Silver Winner
• Stevie® Awards for Sales & Customer Service: Most Valuable Response by a Customer Service Team (COVID-19). Bronze Winner
• Best in Biz Awards: Most Customer-Friendly Company of the Year – Medium and large category (Silver)

2020:

• National Customer Service Association All-Stars Award: Organizations of 100 or Greater, Runner-Up
• Communicator Award of Distinction: October 2019 Broker News
• MarCom Awards: Gold, COVID Staycation Ideas brochure
• MarCom Awards: Platinum, 2021 Well-being Calendar
• Best in Biz Awards: Most Customer-Friendly Company of the Year - Medium category (Silver)

Health Advocate is an Equal Opportunity Employer that does not discriminate on the basis of race, color, sex, age, religion, national origin, citizenship status, military service and veteran status, physical or mental disability, or any other factor not related to job requirements. We respect and value diversity, and are committed to the principles of Equal Employment Opportunity.

VEVRAA Federal Contractor requesting appropriate employment service delivery systems, such as state workforce agencies and local employment delivery systems, to provide priority referrals of protected veterans.

PAY TRANSPARENCY NONDISCRIMINATION PROVISION

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-I.35(c)