Appeals Specialist

1 week ago


Sandton, South Africa HR Studio Full time
Job Overview

We are seeking a skilled Appeals Specialist to join our team at HR Studio. As an integral part of our claims resolution process, you will play a critical role in ensuring timely and accurate resolutions to member and provider appeals.

Key Responsibilities
  • Analyze appeal issues and relevant claims using established guidelines and tools.
  • Collect and analyze verbal and written complaints and appeals from members and providers, identifying key factors that impact resolution.
  • Maintain detailed records of all complaints, resolutions, and documentation for tracking and auditing purposes.
  • Draft response letters for member and provider appeals, ensuring clear and concise communication.
  • Serve as a subject matter expert on appeals, providing guidance and support to internal teams and external stakeholders.
  • Act as a liaison between members, providers, regulatory agencies, and internal teams, coordinating with key individuals regarding appeal decisions.
Requirements
  • Matric or equivalent; associate's degree preferred.
  • Minimum 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.
  • Able to maintain confidentiality and exercise discretion in handling sensitive information.
What We Offer
  • A competitive salary range of $65,000 - $85,000 per annum.
  • Ongoing training and development opportunities to enhance your skills and expertise.
  • A dynamic and supportive work environment.
  • The opportunity to work with a talented team of professionals who share your passion for delivering exceptional service.


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