Appeals Analyst Jobs

• Review and interpret product and benefit designs according to State and Federal regulatory requirements

Education: Associates Degree or equivalent experience in health care, conflict resolution or related field.

• Health care benefit and regulatory knowledge preferred

• 3-5 years health care or insurance experience

• Knowledge of insurance products, policies and procedures preferred.

• Requires excellent interpersonal skills in order to communicate and work with multiple constituents.

5 years of analytical skills and experience (query data, excel, and SharePoint)

Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.

Guides staff by providing technical knowledge and functions as a subject matter expert to staff.

Experience with process improvement initiatives

Serves as a lead for incoming analysts by providing support.

Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.

Perform other duties as assigned by management.

Develop and administer schedules, performance requirements; may have budget responsibilities.

Manage teams and staff assigned.

In some instances this manager may be responsible for a functional area and not have any subordinate employees.

Follow processes and operational policies in selecting methods and techniques for obtaining solutions.

Act as advisor to subordinate(s) to meet schedules and/or resolve problems.

Excellent organizational and time management skills.

Continuing education funds for additional certifications and certification renewal

Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR three years clinical.

Working knowledge of word processing software.

Strong clinical experience, including home health, rehabilitation, and broad medical surgical experience.

Knowledge of specific criteria/protocol sets and the use of the same.