Appeals Specialist II
Reference Code: 4262
Position Title: Appeals Specialist II
Duration: 3 months contract with possible extension
Desired Start Date: 9/28/2020
Location: Long Beach, CA, 90802
Position will start remote, however will be transitioned to onsite position once offices reopen in 2021. Ideal candidate should be located in LA/OC area in California.
Must have requirements: Experience in grievance process or escalated complaint resolution, excellent verbal and written communication skills, experience in Managed Care Plan
Day to day responsibilities: Process high volume of grievances, review complaints, identify issues, investigate events that led to complaint by communicating with internal partners, providers and members, compile findings, provide a comprehensive resolution to members.
- Manages submission, intervention and resolution of appeals, grievances, and/or complaints from members and related outside agencies as a part of the integrated Healthcare Services Team.
- Conducts pertinent research, evaluates, responds and completes appeals 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.
- Enters denials and requests for appeal into information system and prepares documentation for further review. Researches issues utilizing systems and clinical assessment skills, knowledge and approved Decision Support Tools in the decision making process regarding health care services and care provided to members.
- Assure timeliness and appropriateness of all Provider appeals according to state and federal and Healthcare guidelines.
- Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research. Evaluates for medical necessity and appropriate levels of care and formulates conclusions per protocol.
- Collaborates with Medical Directors and other team members to determine appropriate responses.
- Obtains Medical Director approval for determination per protocol. Work with Customer Service to resolve balance bill issues and other member complaints regarding providers. Prepare responses to provider grievances / appeals.
- Elevates appeals to the appropriate committee and/or manager per protocol. Prepares and assists in the preparation of the narratives, graphs, flowcharts, etc. to be utilized for presentations and audits.
- Coordinates workflow between departments and interface with internal and external resources.
- Receive and resolve provider inquiries related to claims.
- Act as a liaison between the providers and health plan as appropriate.
- Assist with interdepartmental issues to help coordinate problem solving in an efficient and timely manner. Identifies and refers cases appropriately for Health Management, Case Management, Quality Improvement and Health Education per established triggers.
- Documents referral according to Healthcare process. Creates and/or maintains statistics and reporting.
- 2-4 years of Utilization Review experience and Managed Care experience.
- Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials