Sr Appeals Specialist

Medical Mutual
US - Ohio - Cleveland
January 8, 2025

Researches, reviews and responds to member and/or provider appeal issues in accordance with departmental policies and procedures, and outside regulatory agency requirements. Serves as a resource for internal and external questions related to member and provider appeal issues, including identifying needed system changes and contacting other areas to implement those changes.

Responsibilities

•Reviews and evaluates appeal/grievance requests and electronic inquiries in order to identify and classify appeals and grievances as outlined in policies and procedures. Using internal systems, determines eligibility, benefits, and prior activity related to the claims payment or service denial issues related to appeal requests. Completes cases within the Center for Medicare & Medicaid Services (CMS) timeframes.

•Utilizes the appropriate systems and resources to communicate, in writing, findings, decisions, rationale for denial or approval and follow-up on corrective action as requested. Completes claims adjustments as needed.

•Identifies and requests internal/external documentation as needed for medical necessity appeal issues and submit cases to appropriate area for review.

•Facilitates processing of Medicare appeals to the independent review entity (IRE) . Documents IRE responses on applicable systems.

•Serves as a resource/training for appeals and grievances unit staff and as a resource for internal/external questions related to appeals and grievances processing issues. Researches, responds and makes recommendations for possible resolution to issues.

•Research complex and sensitive cases received through the Complaint Tracking Module (CTM) as needed.

•Contacts customer or provider by phone for additional information or clarification. Follows up with written correspondence.

•Attends meetings and/or participates in special projects as needed.

•Monitors inventory and manages work distribution.

•Performs other duties as assigned. Qualifications Education and Experience:

•Bachelors' Degree in Business Administration or related field preferred, but will consider collective experience, training and education.

•5 years as an Appeals Specialist or equivalent experience in Medicare health insurance claims, customer service, billing or related operations preferred.

Professional Certification(s):

•Certified Professional Coder (CPC) preferred

Technical Skills and Knowledge:

•Strong knowledge of claims operations and customer service policies, procedures and systems.

•Strong knowledge of claims adjudication, medical terminology, medical/hospital procedure and diagnosis coding and benefits interpretation.

•Intermediate MS Office Skills.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
Discounts at many places in and around town, just for being a Medical Mutual team member.
The opportunity to earn cash rewards for shopping with our customers.
Business casual attire, including jeans.

Excellent Benefits and Compensation:

Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority.
Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

Career development programs and classes.
Mentoring and coaching to help you advance in your career.
Tuition reimbursement up to $5,250 per year, the IRS maximum.
Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.

Read the full job description and apply online on the recuiter's web-site

Sr Appeals Specialist

Sr Appeals Specialist

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