Senior Appeals Specialist

2 days ago


Sandton, South Africa HR Studio Ltd Full time
Job Title: Senior Appeals Specialist - Claims Resolution Expert

About the Role:
We are seeking a highly skilled and experienced Senior Appeals Specialist to join our team at HR Studio Ltd. As a key member of our appeals department, you will play a vital role in analyzing and resolving complex claims and authorization appeals.

Key Responsibilities:
• Conduct thorough research and analysis of appeal issues and relevant claims using established guidelines and tools.
• Collect, analyze, and report verbal and written complaints and appeals from members and providers.
• Make determinations on assigned appeal issues based on sound judgment and available resources.
• Draft response letters for member and provider appeals while maintaining accurate and detailed records of all complaints, resolutions, and documentation.
• Serve as a subject matter expert on appeals, ensuring accurate record-keeping and status updates on all appeals.
• Collaborate with internal teams and regulatory agencies to ensure seamless coordination regarding appeal decisions.
• Work closely 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' experience in 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.
• Proficiency in Microsoft Office.
• Ability to maintain confidentiality and exercise discretion when handling sensitive information.

Working Conditions:
This position entails 3-6 weeks of training, which will commence at 2 pm and conclude at 11 pm. Following training, working hours will be 9 am to 6 pm.

Salary Information: The estimated salary for this role is around $60,000-$80,000 per annum, depending on location and experience.

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