Claims Appeals Specialist

Job Description

Job Description

Who we are :

ManhattanLife Insurance and Annuity Company was founded in 1850, the Company’s longevity makes it one of the oldest and most reliable health and life insurance companies in the country.

Operating successfully for 174 years is a testimony to ManhattanLife’s enduring history, and an indicator of the reliability of our future.

ManhattanLife’s headquarters are in Houston, TX and the company is continually growing with multiple office locations nation-wide.

ManhattanLife offers attractive employee benefits starting day one, including immediate coverage under our health, dental and vision plans.

We offer flexible schedules, including shortened hours on Fridays, free parking, company-wide events, professional development (LOMA testing) and a company-wide wellness program.

Scope and Purpose :

The Claims Appeals Specialist is responsible for ensuring professional and compliant processing of all appeals, predetermination requests, consumer grievances, department of insurance inquiries, and legal inquiries in a timely and efficient way, in accordance with corporate and insurance regulatory standards.

Duties and Responsibilities :

• Reviews and research appeal and complaints submitted on marketed health insurance policies.
• Corresponds with policyholders and / or applicable third party as required (written acknowledgement and closure letters and telephone contact as appropriate).
• Completes data entry and documentation requirements in multiple systems.
• Acts as a liaison and coordinates functions with internal departments relative to the status of an inquiry and the research needed.
• Interacts with Claim Examiners, Claim Department Management, Company Officers, as well as our Legal Department, to resolve the inquiries that are received.
• Responsible for compliance with all regulatory and department timelines.
• Reviews predetermination requests and relevant medical records to determine patient eligibility and to provide benefit estimates to providers as requested.

Minimum Qualifications :

Bachelor’s Degree in English, Business Administration, Government or Communications and / or related field.

Knowledge, Skills, and Abilities :

• 1-3 years of working in a professional office setting.
• Effective interpersonal skills as well as excellent written and verbal communication skills are essential.
• Experience working with Microsoft Word, Excel, and SharePoint is preferred.
• Knowledge or certification of basic medical terminology is a plus.
• Experience with medical billing / coding is preferred.
• Good time management skills and able to work on multiple tasks at a time.
• Knowledge or certification of CPT / HCPCS / ICD9 / ICD10 coding is a plus.
• Prior experience handling predetermination requests, consumer, appeals, or complaints is a plus.

Travel Requirements :

This position may require light travel within a ten-mile radius from one office location to another as needed.

Professional Development :

• Establish annual objectives for professional growth.
• Keep pace with developments in the discipline.
• Learn and apply technologies that support professional and personal growth.
• Participate in the evaluation process.

Physical Demands :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee is regularly required to stand;

walk; use hands to finger, handle or feel objects, type, and use mouse; reach with hands and arms and talk and / or hear.

The employee is required to sit for extended periods of time. The position may require lifting, pulling, or moving items weighing upwards of 10 pounds as it relates to office or desk supplies.

Work Environment :

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee regularly works in an office environment.

This role routinely uses standard office equipment such as computers, phones via WebEx, physical phone while in office, and photocopiers when necessary.

Other Duties :

Please 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.

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to the job at any time without notice.

AAP / EEO Statement :

ManhattanLife prohibits discrimination based on race, religion, gender, national origin, age, disability, veteran status, marital status, pregnancy, gender expression or identity, sexual orientation, or any other legally protected status.

EOE Employer / Vet / Disabled. ManhattanLife values differences. We are committed to fostering an environment that attracts and retains a diverse workforce.

With individuals from a variety of backgrounds, ManhattanLife will be better equipped to service our customers, increase innovation, and reduce risks.

We encourage the unique perspectives of individuals and are dedicated to creating a respectful and inclusive work environment.