Appeals Representative

The purpose of this position is to handle the end-to-end member appeals process. This individual is responsible for analyzing plan documents, processing claim adjustments, negotiating payments with providers, identifying trends, and conducting analysis to determine opportunities for process improvements or benefit changes. The Appeals Representative is responsible for the handling, tracking, and reporting of all levels of member appeals, including referrals to Trustees and/or Independent Review Organizations (IRO). This individual must possess excellent communication and organizational skills and can work independently. The Appeals Representative collaborates and builds key relationships with all levels of the organization, including Regional Directors, Executives and Trustees. This role will provide excellent customer service to internal and external customers while meeting all applicable compliance requirements.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Responsible for the end-to-end handling of member appeals, open negotiations, and Independent Dispute Reviews (IDR)
• Ensures all member appeals are resolved by the determined deadline, based on the type and level of appeal.
• Analyzes benefit, clinical, compliance and claim processing information to determine the course of action.
• Requests additional documentation from members or providers when necessary (e.g., medical records, billing statements, etc.)
• Prepares necessary documentation and appeal resolution recommendations to Regional Directors and Trustees
• Communicates appeal resolution to members in writing.
• Coordinates and partners with medical management to ensure accurate benefit determination.
• Prepares and refers appeals to Independent Review Organizations (IRO) when applicable.
• Performs root cause analysis and identifies trends to improve member experience or enhanced benefit design.
• Triages member appeals with managed care vendors to ensure they are handled in an accurate and timely manner.
• Generates and distributes daily, weekly, and monthly reports to all internal stakeholders.
• Executes claim payment negotiation with providers when applicable.
• Establishes and maintains effective working relationships with peers, vendors, providers, and Executive leadership.
• Works well under pressure and handles multiple cases at the same time.
• Cross-trains on other functions within the Claims Department as needed.
• Processes Short Term Disability claims and reviews disability inquiries and documentation
• Horizon OON Facility Claims -
• Set goals and achieve measurable results.
• Contributes ideas to plans and achieve department goals.
• Demonstrates the Fund’s Diversity and Inclusion (D&I) principles in their conduct at work and contributes to a safe inclusive culture with equitable opportunities for success and career growth.
• Exemplifies the Fund’s BETTER Values in contributing to a respectful, trusting, and engaged culture of diversity and inclusion.
• Performs other duties as assigned within the scope of responsibilities and requirements of the job.
• Performs Essential Job Functions and Duties with or without reasonable accommodation.

ESSENTIAL QUALIFICATIONS

Years of Experience and Knowledge

• 4 ~ 6 years of direct experience including resolution of highly sensate and complex claims issues
• Appeals experience preferred, but not required.
• Working knowledge and experience in medical claims adjudication, preferably in a multi-employer environment
• Working knowledge of plan design documents and pricing methodologies

Education, Licenses, and Certifications

Skills and Abilities

• Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook)
• Intermediate level Microsoft Excel skills
• Interpersonal and negotiation skills
• Excellent communication skills (written and verbal)
• Exceptional time management, organizational and problem-solving skills
• Proven analytical, mathematical, and decision-making skills.
• Ability to demonstrate good judgment and have excellent critical thinking skills.
• Ability to work independently with minimal supervision in a fast-paced environment.

Hourly range for this position: $24.61~$30.15. Actual hourly rate may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) with potential for hybrid work-from-home arrangement.

We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).