Grievances And Appeals Specialist Jobs

Excellent organizational, customer service, and written and verbal communication skills.

Proficiency in spelling, punctuation, and grammar skills.

Perform non-medical reviews and process redetermination letters ensuring timeliness and accuracy.

Prepare unit reports, analyze, and interpret workload, and process issues utilizing various software tools.

Update letters and documents within the department when necessary.

May gather and prepare documentation for legal inquiries and administrative requests.

• 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.

Required Education: High School Diploma or equivalent

Required Work Experience: Two (2) years of job related experience (healthcare, insurance, banking or call center).

Our Comprehensive Benefits Package Includes

Eligible for up to a $2400 annual bonus.

Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy.

Prepares unit reports, analyzes and interprets workload, and processes issues utilizing various software tools.

Previous experience working with regulatory requirements and direct contact with clients required.

Bachelor’s Degree or equivalent experience.

1 year related supervisory experience in an office setting is required.

Knowledge of general computer software (Excel, MS Word and Access).

Identify and communicate client expectations and regulatory requirements to ensure compliance with member and provider complaints and appeal letters.

Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer).

Do you value care management and quality improvement?

Are you an experienced Appeals Specialist looking for a new challenge?

Excellent verbal and written communication skills.

Requires 3+ years’ customer service experience.

Previous experience in the health care industry preferred

Are you motivated, energetic, and excited to become part of the Kepro team?

Previous customer service, appraisal office, or other office experience.

Bilingual in Spanish - (read and speak) is preferred.

Salary Range: $32,000 to $49,653 DOE

Experience working in care management systems, such as CCMS, TruCare or Hyland

Prior experience in a Managed Care or Healthcare environment

Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes and exceptional organizational skills.

Manage all duties within regulatory timeframes

Bachelor’s degree from an accredited institution or relevant work experience

Prior knowledge of Medicare and Medicaid health plans

Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements

Health care benefit and regulatory knowledge preferred

Must be able to work under normal office conditions and in a remote capacity from home as required.

Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.

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

3-5 years health care or insurance experience

Knowledge of utilization management practice principles and industry standard criteria

Knowledge, skills and abilities required

Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards

Knowledge of Oregon Health Plan benefit package including rules and regulations that pertain to health plan operations

Knowledge of Medicare A and B benefits and regulations that relate to Medicare Advantage plans

Physical Skills and Abilities Required

Identifying areas for improvement and communicating suggestions to management.

Bachelor's degree in Business Administration/Management or a related field.

Investigating and resolving member appeals, complaints, and grievances based on specific regulatory requirements.

Excellent verbal and written communication skills.

1 year of experience in a higher-level role such as Lead or Supervisor.

The employer's Affirmative Action Program affirms their commitment to making reasonable accommodations for individuals with disabilities or special disabled veterans.

Excellent organizational, customer service, and written and verbal communication skills.

Proficiency in spelling, punctuation, and grammar skills.

50% Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy.

30% Prepares unit reports, analyzes, and interprets workload, and processes issues utilizing various software tools.

10% Updates letters and documents within the department when necessary.

10% May gather and prepare documentation for legal inquiries and administrative requests.

· Exceptional time management skills.

· Promote a provider-friendly, customer service-oriented philosophy within the Fresenius Health Partners Utilization Management department.

· Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation and email applications.

· 2 – 4 years’ related experience required

· Medicare Advantage Appeals and Grievance experience required.

· Excellent analytical and leadership skills.

Assigning case files to the department staff for case management.

Responsible for additional clerical/administrative responsibilities at the discretion of the Director or Manager.

Print, mail, and triage letters at the FH corporate office located at 10 Chestnut Street, Worcester, MA.

Managing incoming faxes and member specific data, routing to the appropriate staff member.

Producing, maintaining, and distributing reports/calendars utilized by the team to assist in workload planning.

Processes department incoming/outgoing mail per established workflows in a timely and accurate manner.

Maintains current knowledge of regulatory, contractual and accreditation requirements subject matter expert

2+ years of experience in a managed care healthcare setting

2+ years of Utilization Management (Helpful)

Comprehensive knowledge of Medicaid and Medicare contractual provisions and NCQA accreditation requirements highly desirable

Exceptional customer service skills and experience working with diverse populations required

Assists with calibration sessions in accordance with department standards, to help ensure consistency and validation of audit parameters, KPIs, and requirements

Assists management in process improvement strategies to achieve business objectives.

Prepares audit findings and recommendations for G&A associates and management on a monthly basis.

National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint

Identifies and communicates error trends to improve overall quality of enterprise G&A team.

Associates at this level handle routine audits and may receive guidance from G&A Auditor IIs.

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Keep abreast of changes in market requirements and demonstrate expert knowledge in specific market nuances.

Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management.

Communicate ways to improve processes and procedures to management.

Excellent verbal, written, interpersonal, organizational and communication skills.

Excellent research skills with ability to identify underlying issue(s) not articulated

1 year of experience in a higher-level role such as Lead or Supervisor role.

Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements

Health care benefit and regulatory knowledge preferred

Must be able to work under normal office conditions and in a remote capacity from home as required.

Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.

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

3-5 years health care or insurance experience

Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements

Health care benefit and regulatory knowledge preferred

Must be able to work under normal office conditions and in a remote capacity from home as required.

Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.

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

3-5 years health care or insurance experience