Note: The job is a remote job and is open to candidates in USA. Mindlance is recruiting for an Appeals Analyst role supporting a confidential healthcare organization. The position focuses on researching and resolving appeals, coding disputes, grievances, and coverage determinations, while managing case workloads and ensuring timely, compliant responses.
Responsibilities
- Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines
- Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers
- Regularly and independently exercise judgement to make appropriate decisions based on Client NC policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact
- Prepare files and develops Client NC position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants
- Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines
- Document extensive investigation, relative findings, and actions in all applicable systems
- Accountable for monitoring daily reports to ensure service timeliness and compliance is met
- Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances
- Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance – NCQA), ASO group performance guarantees and BCBSNC policies and procedures (to include BCBSA requirements)
Skills
- Required Skills: Medicare experience, Insurance experience, ability to have time management
- Years of Experience: 3-5 years of experience
- Bachelor's degree or advanced degree where required
- 3 years of related experience
- In lieu of degree, 5 years of related experience
- For coding disputes area, certified professional coder must be obtained within 1 year of employment
- Nice to have Skills: claims experience, appeals and greivance experience
Benefits
- 100% remote work in the listed 28 states
- First two weeks of classroom training
- Job shadowing and on-the-job training for one to two weeks
Company Overview
Company H1B Sponsorship