Appeals Analyst

Immediate need for a talented Appeals Analyst. This is a 12+ months contract opportunity with long-term potential and is located in U.S(Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-70351

Pay Range: $26 - $28/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• 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 s policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
• Prepare files and develops client s 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.) accreditation agency standards (National Committee for Quality Assurance NCQA), ASO group performance guarantees and client s policies and procedures (to include BCBSA requirements).

Key Requirements and Technology Experience:

• Key skills; MUST BE CPC (CERTIFIED PROFESSIONAL CODING) CERTIFIED.
• Care Radius experience.
• Facets experience
• Experience in health insurance industry
• Experience in handling appeals and grievances from providers regarding claim denials.
• Bachelor s degree or advanced degree where required.
• 3 years of related experience
• In lieu of degree, 5 years of related experience
• CPC required
• Able to work with a large team (about 29 others).
• Desk management and organizational skills.

Our client is a leading Health Insurance Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

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