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Appeals Analyst
Job
Mindlance
Remote
Full-Time
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Job Description
Appeals Analyst#26-14779
Durham, NC
Remote Job Description 100% Remote in the 28 states - North Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming will be allowed to maintain their current residence and work remotely. Screening questions
Tell me about a time you had to deal with a difficult customer?
Required Skills:
Medicare experience, Insurance experience, ability to have time management Nice to haveSkills:
claims experience, appeals and greivance experienceYears of Experience:
3-5 years of experienceInterview Process:
Video - 3-5 questions- 30 minutes is typical Two interviewers one round 30 minutes Sherita and team leaderResponsibilities:
- Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.
- Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers.
- Regularly and independently exercise judgement to make appropriate decisions based on Client NC policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
- Prepare files and develops Client NC position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants.
- Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines.
- Document extensive investigation, relative findings, and actions in all applicable systems Accountable for monitoring daily reports to ensure service timeliness and compliance is met.
- Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances.
- Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.