Register
Recruit Create CV
Unfortunately, this job posting is expired.
Don't worry, we can still help! Below, please find related information to help you with your job search.
Related keywords
Some similar recruitments
Medicare Set Aside Specialist
Recruited by Sanderson Firm PLLC 8 months ago Address Florida, United States
Compliance Appeals Specialist, Cash App
Recruited by Cash App 9 months ago Address New York, NY, United States
Grievance & Appeals Quality Assurance Specialist
Recruited by SnugZ USA 9 months ago Address New York, NY, United States
Rn Appeals Nurse (Hybrid)
Recruited by VillageCare 9 months ago Address New York, NY, United States
Grievance & Appeals Specialist- Remote
Recruited by EmblemHealth 9 months ago Address New York, NY, United States
Nurse Appeals Jobs
Recruited by Elevance Health 10 months ago Address Florida, United States
Legal Staffing & Utilization Specialist
Recruited by Considine Search 11 months ago Address New York City Metropolitan Area, United States
Appeals Paralegal Jobs
Recruited by Manhattan District Attorney's Office 1 year ago Address New York, NY, United States
Case Appeals Nurse Jobs
Recruited by Good Samaritan Hospital 1 year ago Address , Suffern, 10901, Ny
Appeals Coordinator Level Ii
Recruited by MedReview Inc. 1 year ago Address New York, NY, United States
Hearings Referee Jobs
Recruited by Judicial Department 1 year ago Address , Portland, Or $102,218 - $158,574 a year

Expedited Appeals Specialist- Remote

Company

ConnectiCare
Address , New York, Ny
Employment type FULL_TIME
Salary $72,000 - $138,000 a year
Expires 2023-07-20
Posted at 1 year ago
Job Description
Summary of Position
  • Perform end-to-end G&A processing; consistently operate in a fast-paced high-pressure environment.
  • Due to regulatory requirements and turn-around times of the Expedited Appeal unit, the Specialists are required to work weekends and holidays as the organization must maintain expedited appeal coverage 7 days a week, 365 days a year.
  • Monitor all aspects of the G&A process; ensure that members have appropriate access to care.
  • Responsible for processing expedited appeals: those that are complex in nature, require multiple hand-offs, and tend to have extremely tight deadlines. Ensure accuracy and compliance within the constraints of extremely quick turnaround times.
Principal Accountabilities
  • Independently perform triage function: review and evaluate appeal requests; identify and classify member and provider appeals. Using internal systems, determine eligibility, benefits, and prior activity related to the claims, payment, or service in question.
  • May train, guide, and mentor new G&A Specialists.
  • Conduct thorough investigations of all member and provider correspondence by analyzing all the issues presented and obtaining responses and information from internal and external entities. Validate the responses to ensure they address the issues and are supported by any contract stipulations, regulations, etc., as applicable.
  • Provide verbal and written member and provider correspondence as needed for authorized representative or needed clinical information.
  • Serve as a coach and mentor to the associates providing support and guidance in complex situations.
  • Serve as liaison with EmblemHealth departments, delegated entities, medical groups, and network physicians to ensure timely authorization effectuation and resolution of cases.
  • Exceed median production and compliance standards for both case resolution and data requirements.
  • Provide recommendations to management regarding issue resolution, root cause analysis and best practices.
  • Perform necessary follow-up with responsible departments and delegated entities to ensure compliance.
  • Identify workflow improvements and work with the team to recommend and implement change(s).
  • Monitor hourly and daily pending reports and personal worklists, ensuring adherence to CMS, NCQA, DOH, NYS, Connecticut and Massachusetts regulatory requirements, as well as operational SLAs and department performance standards, thereby ensuring members’ access to care.
  • Make critical decisions regarding research and investigation to appropriately resolve all inquiries; prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the Plan’s determination; make recommendations on administrative decisions by preparing detailed case summaries and reviewing all applicable benefit and contract materials; present findings and recommendations to appropriate parties for sign-off.
  • Complete submission of case files and responses to entities such as DFS, DOH, AG and Maximus; ensure timely and appropriate response submissions.
  • Perform other duties as directed, assigned, or required.
  • Document final resolutions along with all required data to facilitate accurate reporting, tracking, and trending.
  • Maintain acceptable attendance standard with minimal unscheduled PTO.
  • Serve as a point of escalation for problems, providing guidance and expertise to team members as well as helping to identify and address core business requirements.
  • Independently prepare well written, customized responses to all correspondence that appropriately and completely address the complainant’s issue(s) and are structurally accurate. Responsible for ensuring responses are completed within the applicable regulatory timeframe.
Education, Training, Licenses, Certifications
  • Bachelors’ degree.
Relevant Work Experience, Knowledge, Skills, and Abilities
  • Must be well versed in all aspects of the complaint, grievance and appeal process and be able to process all types of correspondence handled by Grievance and Appeals. (R)
  • Excellent product knowledge. (R)
  • Leadership skills. (P)
  • Additional related experience/specialized training may be considered in lieu of degree requirements. (R)
  • Excellent prioritizing, organizing, time management, problem solving and analytical skills. (R)
  • 3 – 5+ years of related experience, preferably in the health industry and/or area of compliance. (R)
  • Proficiency in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.). (R)
  • Extensive knowledge and experience in claims, enrollment, benefits, and member contracts. (R)
  • Ability to work under pressure and deliver complete, accurate, and timely results. (R)
  • Ability to mentor specialists and to provide assistance on complex cases. (R)

Additional Information

  • Employee Status: Regular
  • Requisition ID: 1000001145
  • Schedule: Full-time
  • Hiring Range: $72,000-$138,000
  • Job Type: Standard