Overview

Quartz is seeking an Appeals Specialist to join our Legal & Compliance Team. This position will play a pivotal role in ensuring fair and accurate resolution of appeals and upholding the high standards of our organization’s dedication to exceptional customer service.

The Appeals Specialist position will facilitate, coordinate, and proactively investigate member appeals, grievances, and regulatory inquiries. Using their problem-solving skills, this position will create a comprehensive case file based on a thorough investigation of oftentimes, complex member concerns. This role will also evaluate various resolution options and exercise independent judgement to determine the best course of action while maintaining excellent customer service relations through courteous communication and accurate handling of member issues.

Benefits:

• Collaborate with leadership to manage resources
• Full-time virtual, work from home environment available
• Starting pay range: $23/hr. - $27/hr. plus robust benefits package

Responsibilities

• Identify and conduct thorough investigations of complex member disputes to prepare complete case files and respond to regulatory inquiries.
• Communicate all necessary verbal and written communications related to the decision of an appeal including but not limited to: members, providers, legal entities, etc. within regulatory timeframes.
• Schedule, coordinate, and facilitate meetings with the review committee, the member, and any other ad hoc representatives.
• Respond to customer inquiries, in a courteous and efficient manner regarding eligibility, verification of benefits and claims payment status via telephone or in person, on an as available/needed basis.
• Investigate customer written inquiries and coordinate with proper internal departments to ensure timely responses are completed.
• Investigate, coordinate, and reply to all written complaints and other regulatory inquires received by the company ensuring that handling of grievances, appeals, and regulatory inquiries comply with applicable state and federal statutes, regulations, and sub-regulatory guidance.
• Develop health plan training programs and conducts training for health plan staff relating to: identifying complaints/grievances/appeals; appropriate documentation and reporting such as disputes; government requirements involving the dispute resolution process and health plan policies and procedures for the various dispute resolution processes.

Qualifications

• High School diploma or equivalent
• 1 year of experience working for Quartz’s customer relations teams (customer success, claims, enrollment, etc.) OR 3 years of intensive customer service experience, preferably in an HMO setting
• Experience with Epic software is preferred
• Developed and proven proper grammar and writing skills
• Working knowledge of personal computer software applications including Microsoft Word and Excel
• Excellent verbal and written communication skills with superior interpersonal skills and the ability to adapt communication style to audience to provide honest and clear messaging
• Ability to work independently, as well as with supervision and cooperatively with co-workers in team situations
• Ability to resolve complex problems in a professional manner, utilizing an understanding of appropriate policies and procedures, employing knowledge of products, and exercising good judgment and reason
• Ability to anticipate obstacles, barriers or gaps and work to continuously improve organizational capability to deliver results

This position can work 100% remotely or from our office in Madison, WI in a hybrid or full-time on-site arrangement, if preferred. Hardware and equipment will be provided by the company, but candidates must have access to high-speed, non-satellite Internet to successfully work from home.

We offer an excellent benefit and compensation package, opportunity for career advancement and a professional culture built on the foundations of Respect, Responsibility, Resourcefulness and Relationships. To support a safe work environment, all employment offers are contingent upon successful completion of a pre-employment criminal background check.

Quartz values and embraces diversity and is proud to be an Equal Employment Opportunity, Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity or expression, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified person with disability.