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