The Appeals Specialist II position plays a critical role ensuring that PEHP member and provider appeals are researched according to Master and Corporate Policy and compiling appeal documentation for review by the PEHP Executive Review Committee and the PEHP Provider Dispute Review Committee. This role performs a variety of reviews for medical, dental, FSAs, and enrollment appeals that have been disputed by members or providers. Successful performance requires knowledge of PEHP policies and various group plan benefits. Fundamental skills include strong letter writing and communication skills, conflict management experience, analysis, and the ability to be a team player. 

This job may be filled at either of the levels listed below.

Appeals Specialist I- Min: $17.75/hr. Max: $22.19/hr. Appeals Specialist II- Min: $19.34/hr. Max: $24.19/hr.

• Researches requests for review of resolvable claims from providers as first level reviews that do not require a certification in coding and billing and have escalated to the Executive level. Compiles information related to member appeals that request an Executive Review.
• Assists other Specialists with various tasks, including but not limited to, submitting second level reviews to Cotiviti or other outside vendor(s), responding to disputes from providers involving direct Master Policy exclusions and/or plan limit maximums, and responding to dispute review requests from members that do not have an appeal form attached.
• Provides copies of necessary documents and submits information to the Appeals and Policy Manager for review. Copies appropriate documents from appeal file, creates information packets, and distributes to members of the Executive Review Committee prior to scheduled meetings. Maintains current data on appeals and resolvable claims.
• Meets with members to coordinate the review of claim payment documents and records that pertain to the appealed claim. Provides copies of such claim’s payment documents and records to members upon request.
• Ensures compliance with state and federal regulations and provider contracts throughout all levels of the appeals process.
• Ensures that denied claims that are approved on appeal are paid promptly and correctly according to the directives of the Executive Review Committee.
• Creates written correspondence to members and providers regarding appeal outcome and benefit determination. Creates written documentation of Executive Review Committee decisions. Documents approval or denial of appeal in the members’ history and in the Case Data Management log.
• Maintains files and documentation relating to the development, updating, and maintenance of the Master Policy and other applicable documents (i.e., Benefit Summaries, Comparison of Benefits, etc.). Submits requests for benefit changes, wording changes, distribution, etc. to the Appeals and Policy Manager. Documents approval and makes certain that the approved changes/modifications are made to all applicable documents. Ensures that changes are communicated to all employees involved in processing Resolvable Claims and Appeals.
• Participates in researching correct coding for specific medical, dental, and pharmacy payment policies and procedures created by Clinical Management. Provides updated information for maintenance to claims payment editing systems.
• Develops and maintains various reports needed to track departmental functions and productivity.
• Is responsible for some imaging tasks.
• Receives referrals from adjuster/customer service, providers, insured members, through screening of claims histories and system automation. Works closely with providers, vendors, and insured members to obtain information including but not limited to history and physicals, treatment plans, progress notes, pre-authorization requests, etc.
• Maintains strict confidentiality.
• Performs other duties as required.

Required Experience

APPEALS SPECIALIST I MINIMUM QUALIFICATIONS

High School diploma and one (1) year of progressively responsible experience performing a variety of technical and administrative duties; or an equivalent combination of education and experience. PEHP experience is preferred.

APPEALS SPECIALIST II MINIMUM QUALIFICATIONS

High School diploma and two (2) years of progressively responsible experience performing a variety of technical and administrative duties related to appeals process including a minimum of one (1) year with PEHP specific experience in claims processing, customer service, benefits resolution, appeals; or an equivalent combination of education and experience.