Appeals Specialist I
Reference Code: 4310
Position Title: Appeals Specialist I
Duration: 6 months contract with possible extension
Desired Start Date: 10/26/2020
Location: Long Beach, CA, 90802
Position will start remote, however will transition to an onsite position once offices reopen in 2021. Candidate must be located in LA/OC area to qualify for the position.
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.
• Resolves and prepares written response to incoming member or provider appeals, grievances, complaints and/or disputes.
• Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
• Identifies potential provider problems through a proactive approach in which data is mined and trended to identify and prevent provider problem areas.
• Uses a variety of references to research and prepare healthcare provider information for loading into the health plan system/database; enters provider demographics, contract affiliation, or other data as needed.
• Interfaces with other departments regarding questions about provider configuration or other relevant provider issues.
• Composes all correspondence and appeal information concisely and accurately, in accordance with regulatory requirements.
• Maintains tracking system of correspondence and outcomes; maintains well-organized, accurate and complete files for all appeals, grievances, complaints and/or disputes.
• Monitors each request to ensure all internal and regulatory timelines are met.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate and collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Healthcare guidelines.
• Prepares appeal summaries, correspondence and documents information for tracking/trending data; assists in the preparation of narratives, graphs, flowcharts, etc. for presentations and audits.
- 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.
- Excellent vocabulary, grammar, spelling, punctuation, and composition skills proven through the development of written communication.
- Maintain regular attendance based on agreed-upon schedule Computer skills and experience with Microsoft Office Products.
- Excellent verbal and written communication skills Ability to abide by policies
- Maintain confidentiality and comply with Health Insurance Portability and
- Accountability Act (HIPAA) and fraud and abuse prevention detection policies and procedures Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
- High School diploma or GED equivalent
- 2-3 years experience in a managed care setting; CPT and ICD-9 coding, data entry, and 10-Key experience.
- 2-3 years managed care experience; claims review and processing background including coordination of benefits, subrogation, and eligibility criteria.