Appeals Representative I

The Appeals Representative is responsible for reviewing, analyzing, and addressing provider inquiries and appeals via email, fax, telephone, or written correspondence in accordance with regulatory guidelines, client policy and instructions, and industry standards, along with CMS and state guidelines. This role ensures that all appeals are set up accurately and in a timely manner, supporting the appeal process efficiently.

ESSENTIAL FUNCTIONS & RESPONSIBILITIES:

• Receiving and analyzing appeal documentation to determine appropriate actions
• Accurately setting up and initiating the appeals process timely, ensuring information aligns with provided documents
• Ensure compliance with HIPAA, CMS guidelines, and client instructions and policy standards
• Utilize applicable tools and resources to complete setup
• Additional duties as assigned

KNOWLEDGE & SKILLS:

• Knowledge o...