The Claim Appeals Specialist researches and resolves member and provider appeals and grievances related to claim payments. This is a full-time position, Monday to Friday 8am-4:30pm, reporting to our Syracuse Office.
Performance Responsibilities and Standards:
- Reviews appeals to ensure appropriate routing based on medical necessity appeals vs claim appeals.
- Researches and makes determinations in response to member and provider claim appeals in compliance with CMS, NYS DOH and plan guidelines.
- Logs, tracks and documents all claim appeals, related follow-up activities and final outcomes in designated systems.
- Prepares written communication of appeal decision in format and language that is clear, accurate and easily understood by providers/ members.
- Works closely with manager to ensure procedures and responses are consistent with plan benefits, contractual agreements and plan established policies and procedures.
- Communicates with members, providers and internal and external customers to discuss appeal results when questions arise.
- Participates in appeals audits to monitor compliance.
- Assists with reporting to CMS, NYS DOH and plan leadership, as necessary.
- Provides courteous, responsive, respectful, and knowledgeable customer service.
- Other duties as assigned.
- High School Diploma or equivalent required.
- Medical billing and/or medical claims handling experience.
- Skilled in prioritizing, problem-solving, multi-tasking, and meeting deadlines.
- Compliance with all agency policies and procedures.
- Exceptional customer service skills.
- PC Skills, including Microsoft Office.
- Discretion in handling confidential and sensitive information
- Excellent communication skills, verbal and written.
- Speaking/visual/hearing ability sufficient to comprehend and express written/verbal communication.
- Frequent sitting, standing, walking
- Pushing, pulling, reaching, kneeling
- Ability to lift and move objects up to 40 pounds
Compensation & Benefits:
Competitive Salary with:
- 401K with generous Employer match
- Medical, Dental, Vision plans
- On-Site Employee Fitness Center and Gym Membership
- Partially funded HSA
- Paid Time Off and Extended Sick Leave
- Short/Long term Disability
- Exceptional work/life balance
- Employee Assistance Program (EAP)
- Much More!
About Nascentia Health:
Nascentia Health is leading the way in home care, post acute care and long-term community health, at our brand new headquarters featuring state-of-the-art technology and an on-site employee gym. We are looking for exceptional people to join our team.
A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.
Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community-based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team.
Nascentia Health is an Equal Opportunity Employer (EOE)
Employment is contingent upon negative results of a pre-hire drug screen