Grievance and Appeals Representative

Appeals & Grievances Specialist – REMOTE

Schedule: Monday to Friday, 9am to 5:30pm PST

Job Description:

  • Seeking candidates with Member and/or Provider Appeals and Grievances experience.
  • Manages submission, intervention and resolution of appeals, grievances, complaints and/or disputes from members or providers and related outside agencies.
  • Conducts pertinent research, evaluates, responds and completes appeals, grievances, complaints and/or disputes and other inquiries accurately, timely and in accordance with all established regulatory guidelines.
  • Prepares appeal summaries and correspondence and documents information for tracking/trending data.

Knowledge/Skills/Abilities:

  • Comprehensive knowledge of health care customer service, regulatory requirements and Provider Dispute and/or Member Appeal process.
  • Knowledge of CPT/HCPC and ICD9 coding, procedures and guidelines.
  • Computer skills and experience with Microsoft Office Products.

Required Education:

High School diploma or GED equivalent

Required Experience:

  • 2 years experience in a managed care setting; CPT and ICD-9 coding, data entry, and 10-Key experience.
  • 2 years claims review and processing background including coordination of benefits, subrogation, and eligibility criteria.

Job Requirements:

  • Refer claims for medical claim review
  • Conduct detailed technical training of non claims processing claims staff
  • Supervise a team of claims adjusters
  • Supervising the processing of claims
  • Help improve claims processing workflow
  • Review and analyze reports on claims adjudication and claims auditing
  • Ensure timely handling of all claims
  • Maintain periodical review of litigated claims, serious vocational rehabilitation claims, questionable claims and sensitive claims as determined by client
  • Ensure all claims processing documentation is
  • Resolve complex escalated claims processing issues
  • Help insurance companies mitigate claims expense and reduce claims cycle time
  • Ensure all conveyances and claims
  • Handle all personal injury claims
  • Demonstrate understanding of automated claims processing
  • Reduce overall cost of processing claims
  • Provide formal training on claims processing guidelines
  • Execute appropriate claims activities to ensure consistent delivery of quality of claims service
  • Perform system testing of claims processing system
  • Handle the most complex, difficult claims and adjust controversial claims
  • Help improve claims processing workflows, efficiencies

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