Appeals Specialist I (Remote)

**Resp \& Qualifications** **PURPOSE:** The Appeals Specialist I is responsible for the initial analysis of appeals and/or grievance correspondence, and determination of next steps for the following line of business: Commercial. The incumbent is responsible for collecting, organizing and tracking information to facilitate and expedite processing of appeals and/or grievances received from a variety of sources. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business\-related activities. The ideal candidate will have previous experience working with appeals and grievances in a healthcare payor organization. **ESSENTIAL FUNCTIONS:** * Prioritize, research and analyze all pertinent information of an appeal and/or grievance request. Access the appropriate technology platform to implement accurate and timely entry of an appeal, grievance and/or reconsideration correspondence and updates the appropriate referral source communication system. Review appropriate benefits and processing guidelines. Submit cases to the nurse for research/decisions and claims department for adjustments and/or claim updates. Performs and manages general mail and/or printing duties and other needs as requested per the needs of the department. * Utilizes professional written and verbal communications to request additional documentation to assist in response of all appeals and/or grievances based on State and Federal requirements for all lines of business. Interacts regularly with and responds to internal and external stakeholders, without breaching confidentiality of medical information. * Assists Supervisor and Appeals Specialists II and III with unit projects and other duties related to the appeals, grievance and/or reconsideration processes. Communicates with Supervisor to offer feedback regarding continuous improvement of unit workflow and processes. Actively participates in monthly meetings and discussions regarding quality, appeal and/or grievance research, data entry and helps to resolve any issues regarding the appeal and/or grievance intake and entry/documentation process. **QUALIFICATIONS:** **Education Level:** High School Diploma or GED. **Experience:** 3 years experience in settings such as managed care, health care or insurance payor environment. **Preferred Qualifications:** * College Degree. * Knowledge of CareFirst systems, Member/Provider Service, Claims or Care Management experience. **Knowledge, Skills and Abilities (KSAs)** * Knowledge and understanding of medical terminology. * Demonstrated problem solving and decision\-making skills, including the ability to exercise good judgement. * Strong organizational and analytical skills. * Strong verbal and written communication skills using proper grammar and ensuring all correspondence is in lin