The Delta Health Systems Benefit Review Appeal Specialist performs comprehensive research related to the facts and circumstances of Plan Participant and Provider complaints, appeals, and grievances. This position is required to apply contract language, benefits, and covered services in researching and providing an accurate and appropriate resolution following Self-Funding Plan Documents, NAIC Regulations, and CMS Guidelines. The Delta Health Systems Benefit Review Appeal Specialist performs comprehensive research related to the facts and circumstances of Plan Participant and Provider complaints, appeals, and grievances. This position is required to apply contract language, benefits, and covered services in researching and providing an accurate and appropriate resolution following Self-Funding Plan Documents, NAIC Regulations, and CMS Guidelines.
- Handle phone inquiries from Plan Participants, Providers, and Internal Departments
- The ability to interpret medical terminology
- Strong understanding of CPT, CDT, HCPCS, Revenue, and ICD10 coding structures
- Ability to read, understand and interpret Client Summary Plan Documents, NAIC Regulations and Guidelines, CMS Guidelines, and Network Medical Policies.
- Have good organizational skills and the ability to manage time, and resources effectively.
- Understand Usual and Customary concepts, claim calculation, and validation
- Complies with department policies and procedures
- Sound numeric skills – detailed and accurate
- Knowledge of Coordination of Benefits (COB)
- Knowledge of Third-Party Liability (TPL)
- Advanced computer skills, particularly in Word and Excel, basic knowledge of database applications.
- Strong communication skills both written and verbal
- Provide written responses to appeals and complaints, while providing facts, clarifying, and educating in Plan Benefit Details.
- Interpret and explain plan benefits, policies, procedures, and functions to Plan Participants, Providers, and Internal Departments.
- Create appropriate and accurate acknowledgment and resolution letters
- Provide a written response to appeals and complaints, while clarifying, and educating in Plan Benefit Documentation.
- Perform to standard department metrics based on established goals and objectives
- Create claim processing medical policies in accordance with Plan Document and Industry Standards to ensure accurate claim adjudication.
- Provide written Pre-Determination of Benefit response in accordance with Plan Document.
