Appeals Specialist

1 week ago


Sandton, South Africa HR Studio Ltd Full time
Appeals and Complaints Resolution Specialist

Job Summary: We are seeking a highly skilled Appeals and Complaints Resolution Specialist to join our team at HR Studio Ltd.

Key Responsibilities:

  • Utilize guidelines and tools to conduct research and analyze appeal issues and relevant claims.
  • Collect, analyze, and report verbal and written complaints and appeals from members and providers.
  • Analyze and make determinations on assigned appeal issues.
  • Draft response letters for member and provider appeals.
  • Maintain detailed records of all complaints, resolutions, and documentation for tracking and auditing purposes.
  • Serve as a subject matter expert on appeals, ensuring accurate record-keeping and status updates on all appeals.
  • Act as a liaison between members, providers, regulatory agencies, and internal teams; coordinate with key individuals regarding appeal decisions.
  • Work with internal subject matter experts to obtain benefit and/or clinical opinions and interpretations of complex cases.

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.

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