Medical Claims Appeal Specialist

**Job Summary**:
The Appeals Specialist I will analyse and resolve verbal and written claims and authorisation appeals through coordination with providers and members. This position will prepare responses within required timeframes and track the status of all appeals with exemplary record-keeping. The client is internationally based, so after-hours work, aligned with the client’s business hours in their country, will be required. This is a fixed-term role with the potential for permanent employment, based on the client’s ongoing needs.

**Duties and Responsibilities**:

- Use guidelines and tools to conduct research and analyse appeal issues and pertinent claims
- Gather, analyse and report verbal and written member and provider complaints and appeals
- Analyse and complete determinations on assigned appeal issues
- Prepare response letters for member and provider appeals
- Maintain detailed records of all complaints, resolutions and documentation for tracking and auditing purposes
- Serve as liaison between member, provider, regulatory agencies and internal teams; coordinate with key individuals regarding appeal decisions

**Required Knowledge, Skills, and Abilities**:

- High school diploma or equivalent; associate’s degree preferred
- 2+ years grievance and appeals, claims or related healthcare experience, preferably in a carrier or TPA setting
- Familiarity with CMS standards and requirements related to complaint resolution

**Job Type**: Temp to perm

Pay: R12 000,00 - R20 000,00 per month