Appeals Specialist (Remote)

LOCATION: Remote - this is a home based, virtual position that operates within the hours of 8:30am-5:00pm EST. Candidate must reside in North Carolina or within 40 miles of the NC border. Must be able to travel to Vaya's Asheville NC office as needed.

GENERAL STATEMENT OF JOB

The Member and Recipient Appeals Specialist is responsible for conducting and supporting the functions of the Member and Recipient Appeals Team in managing the peer review, denial and appeal functions for Vaya Health. Duties include generating member and recipient notification letters, the posting and mailing of correspondence and the scanning and uploading of documents to member and recipient files and Vaya databases.

This position is also responsible for answering and responding to phone calls, emails and faxes with questions from staff, providers, members and recipients, and community members who have needs related to administrative and clinical denials and appeal functions.

ESSENTIAL JOB FUNCTIONS

Member and Recipient Correspondence:

• Preparing, copying, printing and mailing denial and appeal notifications
• Reviewing clinical rationales for required reading level
• Receiving and validating appeal requests
• Proof reading and verifying accuracy of information for member and recipient correspondence.

Peer Review Coordination:

• Coordination and tracking of appeal referrals to appeal Peer Reviewers
• Providing technical and administrative support to Peer reviewers for documentation retrieval and review
• Providing peer review desk coverage to UM staff for referrals to initial Peer Reviewers

Appeal File Administration:

• Preparing and maintaining initial and first level denial and appeal files
• Auditing all levels of Member and Recipient denial and appeal files

Member and Recipient service:

• Answering and responding to phone calls, voicemails, emails and faxes from staff, providers, members and recipients and community members who have questions and needs related to clinical denial and appeal functions.

Data tracking administration:

• Preparing and submitting denial and appeal information to designated tracking spreadsheets and databases
• Documenting and reporting anomalies or errors to the Member and Recipient Appeals Manager

Other duties as assigned.

***Note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

KNOWLEDGE, SKILL & ABILITIES

• The ability to maintain a professional and collaborative working relationship with team members, other Vaya staff and external parties.
• Strong attention to detail and superior organizational skills
• Excellent telephone and customer service skills
• Proficient technology skills in Microsoft Office suite, including Word, Excel and Teams
• Ability to multitask and prioritize competing deliverables and complete projects on time
• Ability and comfort in adapting and adjusting to multiple demands, shifting priorities and rapid change

QUALIFICATIONS & EDUCATION REQUIREMENTS

High School diploma or GED required. Associate or Bachelor's degree in Business Management or Certification in Allied Health field preferred.

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.