Appeals Specialist II
Appeals Specialist II
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1 Vacancy
Job Description
Position: Appeals Specialist II
Location: Reston VA #REMOTE
Duration: Long term
Job Description:
- The Appeals Specialist II will be responsible for the initial intake analysis of appeals/grievances correspondence and determination of next steps with minimal supervision for Government Program lines of business. Responsible for collecting organizing and tracking information to facilitate and expedite processing of appeals and grievances received from a variety of sources.
- Responsible for more complicated high level research of cases and other special projects as well as serving as a subject matter expert.
- Provides resolution to problems that are readily identifiable with limited scope and are resolved in accordance with standard practices procedures applications or routines.
- Problem/Task resolution timeframe: The majority of tasks typically take one to two days to resolve.
- Under general supervision proceeds alone or regular duties referring questionable cases to supervisor.
- Failure to accomplish results can normally be overcome without significant effect on the organization
- Contacts are primarily within the department or function with occasional cross-functional interfaces. Some limited external customer contact on routine matters.
- Education Level: High School Diploma or GED
- 5 years experience in settings such as managed care health care or insurance payor environment
- 2 years experience in Appeals Management
- Must have previous experience with A&G experience working in Guiding Care attention to detail ability to work independently with little to no direct supervision and willingness to help others
- Research and Problem Solving Skills Advanced
- Ability to lead train coach and mentor less experienced team members. Advanced
- Ability to work both independently and as a member of a team with minimal supervision. Advanced
- Excellent organizational and analytical skills. Advanced
- Knowledge and understanding of medical terminology. Advanced
Preferred Qualifications:
- College Degree
- Knowledge of Member/Provider Service Claims or Care Management experience a plus.
ESSENTIAL FUNCTIONS:
50% Independently researches contractual benefits limitations & exclusions and claims to assist medical professional staff in performing the review of appeals grievances and reconsiderations. Prioritize research analyze and perform accurate data entry for more complex appeals and grievances including high profile and escalated cases timely or expeditiously. Performs other duties such as file coordination activities including but not limited to filing of all active files purging of files for transport to off-site storage.
25% Utilizes professional written and verbal communications to assist in responses of all appeals and reconsiderations based on State and Federal requirements for all lines of business. Coordinates and completes vendor auditing duties as needed. Reviews researches problematic correspondence and works on special projects with Appeals Nurse or Management.
25% Interacts regularly with and responds to internal and external stakeholders without breaching confidentiality of medical information. Actively participates in monthly meetings and discussions regarding quality appeal research data entry and to problem solve any issues regarding the appeal intake/entry process.
Thanks & Regards
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LAXMAN
Team Lead - Talent Acquisition
KMM Technologies Inc.
CMMI Level 2 ISO 9001 ISO 20000 ISO 27000 Certified
Employment Type
Full-time
