Appeals Specialist
1 week ago
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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Appeals Specialist
2 weeks ago
Sandton, South Africa HR Studio Ltd Full timeJob Title: Appeals SpecialistWe are seeking an experienced Appeals Specialist to join our team at HR Studio Ltd. As an Appeals Specialist, you will be responsible for analyzing and resolving verbal and written claims and authorization appeals through coordination with providers and members.Key Responsibilities:Utilize guidelines and tools to conduct research...
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Appeals Specialist
2 weeks ago
Sandton, South Africa HR Studio Full timeWe're seeking a skilled Appeals Specialist to join our team at HR Studio.This role involves analyzing and resolving verbal and written claims and authorization appeals through coordination with providers and members.You will be responsible for:Utilizing guidelines and tools to conduct research and analyze appeal issues and relevant claims.Collecting,...
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Appeals Specialist
2 weeks ago
Sandton, South Africa HR Studio Ltd Full timeWe are seeking a highly skilled Appeals Specialist to join our team at HR Studio Ltd. This role is responsible for analyzing and resolving verbal and written claims and authorization appeals through coordination with providers and members.The ideal candidate will have the ability to communicate clearly and professionally with internal and external customers,...
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Claims Appeals Specialist
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Sandton, South Africa HR Studio Full timePosition Overview: We are seeking a dedicated Appeals Specialist who will be responsible for evaluating and resolving both verbal and written claims and authorization appeals. This role involves close collaboration with healthcare providers and members to ensure timely and accurate responses while maintaining meticulous records of all appeals. Key...
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Claims Appeals Specialist
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Sandton, South Africa HR Studio Full timePosition Overview: We are seeking a dedicated Appeals Specialist who will be responsible for the thorough analysis and resolution of both verbal and written claims and authorization appeals. This role involves effective coordination with healthcare providers and members, ensuring timely preparation of responses while maintaining exemplary record-keeping...
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