Appeal Specialist

At our company, our mission starts with our people. Guided by our HEART values of Humility, Excellence, Accountability, Respect, and Trust, we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. As an Appeal Specialist, you’ll educate and support members through appeals, external medical review, and fair-hearing processes. You’ll serve as a primary point of contact, provide advocacy and timely communication, and help ensure requests are processed accurately and in accordance with regulatory requirements.

Job Duties & Responsibilities

• Educates members about their rights, responsibilities, benefits, complaints, appeals, external medical review, and fair-hearing processes
• Advocates for members by gathering necessary information and supporting appropriate representation throughout the resolution process
• Researches complex concerns, collaborates with internal departments and external resources, and communicates resolution plans to affected parties
• Monitors real-time queues, adherence reports, service levels, response times, and escalation plans
• Collaborates with claims, eligibility, provider relations, business operations, and other teams to resolve member and provider concerns
• Translates member correspondence and documentation between English and Spanish and provides medical interpretation for Spanish-speaking members and clinical staff
• Assists with referrals to case management, service coordination, and population health programs as needed
• Initiates and supports external medical review and fair-hearing requests through applicable state systems
• Coordinates documentation with internal teams and delegated partners to support external medical review and fair-hearing requests
• Supports medical leadership with external medical review and fair-hearing processes and facilitates internal pre-fair-hearing meetings
• Monitors regulatory compliance, ensures determinations are implemented within required time frames, and submits required documentation to state agencies
• Documents external medical review and fair-hearing activities accurately in utilization management systems
• Provides information for required internal and external reports
• Collects and verifies member and provider information for prior authorization and appeal requests using available systems and resources
• Uses medical terminology and coding knowledge to ensure information is complete for clinical review
• Identifies process-improvement opportunities, supports action plans, and participates in department projects and committees
  

Qualifications

• High school diploma or GED required
• Community Health Worker certification issued by the Texas Department of State Health Services required
• Four years of fundamental utilization management experience required
• Two years of direct experience with utilization management prior authorizations, appeals, fair hearings, and external medical review preferred

Job Duties & Responsibilities

• Educates members about their rights, responsibilities, benefits, complaints, appeals, external medical review, and fair-hearing processes
• Advocates for members by gathering necessary information and supporting appropriate representation throughout the resolution process
• Researches complex concerns, collaborates with internal departments and external resources, and communicates resolution plans to affected parties
• Monitors real-time queues, adherence reports, service levels, response times, and escalation plans
• Collaborates with claims, eligibility, provider relations, business operations, and other teams to resolve member and provider concerns
• Translates member correspondence and documentation between English and Spanish and provides medical interpretation for Spanish-speaking members and clinical staff
• Assists with referrals to case management, service coordination, and population health programs as needed
• Initiates and supports external medical review and fair-hearing requests through applicable state systems
• Coordinates documentation with internal teams and delegated partners to support external medical review and fair-hearing requests
• Supports medical leadership with external medical review and fair-hearing processes and facilitates internal pre-fair-hearing meetings
• Monitors regulatory compliance, ensures determinations are implemented within required time frames, and submits required documentation to state agencies
• Documents external medical review and fair-hearing activities accurately in utilization management systems
• Provides information for required internal and external reports
• Collects and verifies member and provider information for prior authorization and appeal requests using available systems and resources
• Uses medical terminology and coding knowledge to ensure information is complete for clinical review
• Identifies process-improvement opportunities, supports action plans, and participates in department projects and committees

Qualifications

• High school diploma or GED required
• Community Health Worker certification issued by the Texas Department of State Health Services required
• Four years of fundamental utilization management experience required
• Two years of direct experience with utilization management prior authorizations, appeals, fair hearings, and external medical review preferred