Note: The job is a remote job and is open to candidates in USA. Randstad Digital Americas is recruiting a Clinical Appeals Analyst for a managed care organization. The role analyzes, researches, resolves, and responds to clinical appeals, coding disputes, grievances, and coverage determinations while ensuring regulatory compliance, preparing external review files, documenting investigations, and monitoring service timeliness.
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 policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact
- Prepare files and develops 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 policies and procedures
Skills
- Medicare experience
- Insurance experience
- Ability to have time management
- Claims experience
- Appeals and grievance experience
- 3-5 years of experience
Benefits
- Remote work
- Medical insurance
- Prescription insurance
- Dental insurance
- Vision insurance
- AD&D insurance
- Life insurance
- Short-term disability
- 401K plan (all benefits are based on eligibility)
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