Claims Representative

Position Title: Claims Representative

Location: 5525 Reitz Blvd, Baton Rouge, LA 70809 (Remote, but candidates must reside in Louisiana, preferably within 45 miles of Baton Rouge)

Job Duration: 6 months

Pay: $18.86/hour

Position Overview:

The Medical Appeals Representative is responsible for ensuring the timely review and processing of medical appeals. This includes the initial review of incoming appeal requests, prioritizing and categorizing appeals (expedited vs. standard), and ensuring compliance with relevant guidelines (PPACA, DOI, URAC). The role requires proficiency with various software systems and tools (Microsoft Office, JIVA, Facets, ESI, PA Hub, Provider Portal) and involves supporting the department during high volumes or staff absences.

• Medical Appeals Review: Perform initial reviews of medical appeals to differentiate between expedited and standard cases, ensuring compliance with PPACA, DOI, and URAC guidelines.
• Workflow Management: Organize and distribute appeals to the appropriate clinical staff by setting up, tracking, and prioritizing cases using systems like JIVA, Facets, and others.
• Documentation & Communication: Maintain detailed records of medical appeals, and communicate updates to both members and providers, ensuring timely follow-ups and compliance with regulations.
• Collaboration and Support: Assist with duties typically assigned to the Medical Appeals Specialist, especially during peak volumes or staff absences. This includes researching, preparing, routing, and processing appeals.
• Compliance: Ensure the department adheres to relevant policies, accreditation guidelines, and state and federal regulations.
• Process Improvement: Identify areas for improvement in appeal processing and communicate suggestions to the management.

• Education: High School Diploma or equivalent.
• Experience:
• At least 2 years of experience in customer service or claims processing.
• 3 years of insurance experience (including benefits and claims research) is preferred.
• Knowledge of Facets is preferred.
• Skills:
• Strong knowledge of the claims process, CPT, ICD-10, and HCPCS coding systems.
• Proficiency with Microsoft Office (Word, Excel), Zip File Manager, and Adobe Reader.
• Familiarity with medical appeals systems (JIVA, Facets, ESI, PA Hub, Provider Portal) is highly preferred.
• Excellent organizational skills, attention to detail, and the ability to work in a fast-paced environment.

• Location: Candidate must reside in Louisiana (preferably within 45 miles of Baton Rouge).
• Work Environment:
• Primarily performed in an office setting.
• Ability to stand, sit, and engage in activities requiring analysis and documentation.
• Physical Demands: Job duties are typically performed in a normal office environment with regular noise levels. The role involves scanning, printing, and faxing documents.

• This is a non-management role.
• Reports to Supervisor, Medical Appeals.
• Requires communication with internal teams (e.g., Appeals and Grievances, Customer Service, Medical Management) and external entities (e.g., Providers, Legal) to ensure the proper flow of information and compliance with regulations.