Investigates, coordinates and examines appeals and grievances, including conducting research and analysis of complex information in conjunction with established coverage and medical policies. The position communicates regularly with various levels of internal and external personnel and works closely with SelectHealth legal and compliance departments and the Medical Director in their various capacities to resolve complaints. Serves as a resource to various departments regarding appeals and grievance issues and current trends in the appeals arena. Provides feedback to the appropriate staff to avoid future appeals and grievances.
Assess written and verbal complaints, identifying all areas of dissatisfaction and works closely with SelectHealth departments to research and resolve issues that arise in day to day operations.
Maintains a high understanding of various insurance products, medical policies, regulatory requirements, and accreditation standards through available education and individual research.
Extensive knowledge in the health insurance industry, claims adjudication, and benefits for commercial plans, self-funded plans, Medicare, Medicaid, and other government sponsored plans.
Extensive knowledge of SelectHealth operations including utilization/care management, provider relations, enrollment, accounting, and compliance policies and procedures.
- Three years as a Health Benefit Specialist or equivalent experience.
- Intermediate computer literacy in word processing, Facets, and AWD applications.
- Excellent analytical, fact-finding, problem solving and organizational skills as well as the ability to communicate both verbally and in writing with staff, members, and providers.
- Self motivated and experienced in working with minimal or no direct supervision.
- Demonstrated ability to work successfully in a team setting.
- Hearing, Manual Dexterity, Seeing, Speaking
- Previous work experience using medical terminology or the completion of a medical terminology course.
- Demonstrated ability to handle intense emotions and to guide conversations to a satisfactory resolution for all parties.
All positions subject to close without notice
Intermountain Healthcare is an equal opportunity employer M/F/D/V
Intermountain Healthcare - 18 months ago
Intermountain Healthcare is an internationally recognized system of 22 hospitals and a full range of medical services, multi-specialty...