Appeals Specialist

3 weeks ago


Sandton, South Africa HR Studio Ltd Full time
Job Title: Appeals Specialist

We are seeking a highly skilled Appeals Specialist to join our team at HR Studio Ltd. As an Appeals Specialist, you will play a critical role in analyzing and resolving verbal and written claims and authorization appeals.

Key Responsibilities:
  • Analyze and resolve appeal issues and relevant claims using guidelines and tools.
  • Collect, analyze, and report verbal and written complaints and appeals from members and providers.
  • Draft response letters for member and provider appeals.
  • Maintain detailed records of all complaints, resolutions, and documentation for tracking and auditing purposes.
  • Act as a liaison between members, providers, regulatory agencies, and internal teams.
Requirements:
  • Matric Diploma or equivalent; associates 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.
  • Proficient in Microsoft Office.
  • Maintain confidentiality and exercise discretion in handling sensitive information.
What We Offer:
  • 3-6 weeks of training.
  • Opportunity to work with a dynamic team.
  • Competitive salary and benefits package.

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