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H
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing complaint and appeal cases within health insurance, including conducting investigations, preparing comprehensive appeal files, and validating medical claims against regulations. Proficient in communication, analytical problem-solving, and collaboration with internal and external stakeholders to enhance member experience and ensure compliance.
Highest-signal resume keywords
Health Insurance ExperienceClaims Processing KnowledgeMedicare/Medicaid RegulationsMicrosoft Office Suite ProficiencyAnalytical Problem-Solving Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims Policy Guidelines KnowledgeMedical Terminology KnowledgeQuantitative ReasoningComplex Claims ProcessingRoot-Cause AnalysisDocumentation PreparationCase ManagementAppeals HandlingBenefit ConfigurationKeyboarding Proficiency
Soft Skills
Effective CommunicationInterpersonal SkillsTime ManagementDe-Escalation SkillsAnalytical Skills
Industry Keywords
Evidence of CoverageState Medicaid ContractsAdministrative Law HearingsLegal ComplianceStakeholder Coordination
About the role
Key responsibilities & impact- Manage end-to-end complaint and appeal cases
- Conduct investigations by gathering documentation, interviewing stakeholders, reviewing calls, correspondence, and claim history
- Prepare comprehensive appeal files for Leadership Appeals Workgroup, independent external reviewers, Administrative Law Judges, CMS, and State entities
- Present cases to leadership and attend Administrative Law hearings, partnering with Legal as needed
- Draft written determinations, correspondence, denial explanations, and case-specific communications within required turnaround times
- Validate medical claims against Evidence of Coverage or State Medicaid contracts, benefit configuration, and coding
- Coordinate with internal and external stakeholders, business areas, State agencies, and Departments of Banking and Insurance
- Consult Legal, Compliance, and Regulatory Affairs on escalated cases
- Perform root-cause analysis, identify trends and systemic issues, and recommend corrective actions and process improvements
- Authorize administrative exceptions, including higher-threshold claim adjustments
- Maintain detailed tracking and documentation and analyze trends to improve quality and member experience
- Perform other duties as assigned
Requirements
What you’ll need- High School Diploma/GED required
- Bachelor degree preferred or relevant experience in lieu of degree
- Four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries
- Experience in health insurance, claim appeals and grievances preferred
- Experience in complex claims processing necessary
- Prior grievances and appeals handling experience preferred
- Knowledge of insurance claim and membership systems required
- Knowledge of claim processes, benefits, and claim policy guidelines
- Knowledge of medical terminology, COB, Medicare procedures required
- Knowledge of Medicare/Medicaid regulations and guidelines
- In depth knowledge of Claims Policy guidelines required
- Strong knowledge of Microsoft Office Suite required
- Keyboarding proficiency
- Strong language proficiency and clear, effective communication
- Quantitative reasoning and numerical data interpretation
- Ability to read and interpret complex written materials
- Analytical, mathematical, research, problem-solving, interpersonal, de-escalation, and time-management skills
- Ability to manage multiple priorities effectively
- Some travel may be required
Benefits
Comp & perks- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement