Appeals Analyst

Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract to hire opening for an Appeals Analyst. They have over 4 million customers and 5,000 employees dedicated to providing innovative solutions that simplify the healthcare system, improve efficiency and outcomes while reducing costs.

Location: ** While the position is Remote, work from home, you must reside in North Carolina or one of the following states: 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.

Required Skills & Experience

• Bachelor’s degree or advanced degree where required. In lieu of degree, 5 years of related experience
• 3 years of related experience
• Certified Professional Coder (CPC) required
  
  

What You Will Be Doing

• Analyze, research, resolve and respond to confidential/sensitive appeals, 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 policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
• Prepare files and develops position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants.
• Provide comprehensive appeals 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 policies and procedures (to include requirements).

• To be eligible to contract at this client you must be able to pass a drug test and criminal background check Posted By: Andrew Chadwick