Health Admin Services Associate-Voice
Core
Reviewing and processing appeals for denied insurance claims, evaluating reasons for denial, gathering information, and making decisions on appeal resolution to ensure fair and accurate outcomes.
Role type
Health Admin Services Associate (Claims Appeals)
Builds
Health, life, and property & causality claims administration
Domain
Healthcare operations and insurance claims
Deliverable
client delivery
Required skills
Claims administration, medical policy evaluation, clinical guidelines application, documentation analysis, regulatory compliance adherence, communication with claimants, case routing, medical necessity assessment
Preferred skills
Basic computer proficiency, English fluency (US Berlitz B2 or Versant 58+), prior BPO experience
Technologies
Client-specific criteria sets (e.g., Milliman, InterQual), clinical guidelines platforms
Responsibilities
Conduct pre-service and retrospective Provider and Member Appeals for outpatient and inpatient requests; Utilize client-specific criteria sets and medical policies for decision making; Accurately route cases to client medical staff for further review; Conduct medical management review activities; Ensure member access to medically necessary, quality healthcare in a cost-effective setting
Seniority
Junior, individual contributor