Job Description:
• Responsible for Oversight of that that investigates and resolution of appeals scenarios for all products
• Ensure timely, customer focused response to appeals
• Independently coaches others on appeals ensuring compliance with Federal and/or State regulations
• Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases
• Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit
• Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria
• Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial
• Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process
Requirements:
• At least 2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience
• Some Medicare and/or Medicaid knowledge
• Experience in reading or researching benefit language
• Ability to work in fast paced, high volume environment
• Excellent verbal and written communication skills
• Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics
• Solution driven and can handle complex issues with accuracy
Benefits:
• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs