Appeals Associate


Durham, North Carolina

a month ago


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Appeals Associate
Durham, North Carolina

a month ago

Job Description

Title: Appeals Associate
Hours : 8 a.m. to 5 p.m. EST and candidates need to be from an approved conversion State.
Duration: 6 Months to start with a possibility of extension or conversion based on the needs of the business.
: Remote (must be located in any one of the following states only: <style type="text/css">td { border: 1px solid rgba(204, 204, 204, 1) }br { }</style> Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, NC, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.)

This is a non-clinical role and no certications or licenses are required.
Healthcare experience in Appeals/Claims is required and Behavioral Health experience is a plus.
Volume expectation is 40-50 cases per month completed/closed.
Role is to support the claims department with an increase in volume of Behavorial Health claims which is leading to an increase in the appeals deparment overall.  This role is supporting all claims and not just Behavioral Health but experience in Behavioral Health/Mental Health is preferred.
  • Research and investigate all aspects of the member and provider appeals and grievances, NCDOI, Congressional and/or Department of Justice complaints to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), member and provider contract provisions, State and/or Federal requirements, guidelines and/or other mandated requirements (e.g. Thomas Love Settlement), NCQA Standards, Current Procedural Terminology (CPT), ICD-9, and Healthcare Common Procedure Coding System guidelines (HCPCS), as applicable.
  • Investigate member and provider appeals and grievances and NCDOI, Congressional and/or Department of Justice complaints for all lines of business, excluding FEP, by reviewing applicable resources (i.e. CMP, CMS guidelines, CPT coding guidelines, Reconsideration/Appeal Manual, contract provisions, legislation, management, and/or NCQA requirements.
  • Identify, collect, and analyze appropriate documentation from multiple internal systems including claims, customer contract management, benefit booklets, UM systems, coding claim edits, etc. and external sources including pharmaceutical companies, attorneys, providers, Medicare, PBMs, etc.
  • Coordinate and draft responses to NCDOI, Congressional and/or DOJ complaints with all Enterprise Departments to ensure timely and accurate resolution.
  • Consult and confer with medical directors and other clinical staff to ensure the appropriate decision has been made and the approved outcomes are implemented.
  • Review, analyze and make determinations on provider requests for increased payments related to coding and/or bundling issues.
  • Communicate findings of analysis and documentation to appropriate committee, benefit administrators and leadership, as necessary.
  • Initiate claim adjustments on individual cases when necessary and follow and track until completion.
  • Provide written documentation of case determinations to appellants and/or all involved parties (including but not limited to physicians, attorneys, senators/legislators, employer groups, etc.) in a timely manner as required by regulatory mandates and legislation.
  • Identify trends and high-risk issues to mitigate risk of potential legal actions and/or NCOI focused audits and penalties.  Communicate findings to the Legal department, Corporate Communications, Special Investigations, and Healthcare Senior Management.  Make recommendations to address future exposure.
  • Audit appeal and grievance files as required by Federal and/or State regulatory agencies and provide feedback, education and training to individual employees to ensure compliance with mandates.
  • Audit and oversight of entities where delegation of member and provider appeals exists.
  • Identify and take corrective action on appeals or grievances that result from noncompliance of contract provisions, appeal or grievance guidelines, provider contract violations and/or medical policies.
  • Stays current with press releases, emails, and other forms of communications relaying initiatives, contracting issues, as well as Plan wide concerns.
  • Demonstrates high degree of appropriate knowledge of all areas of the plan.
  • Identify and create action plans to educate internal departments on benefit misinterpretation and/or claim payment system errors.
  • Answer member/provider questions via incoming telephone calls in a professional quality driven manner.
  • May handle complaints/grievances as defined by the federal government.

Hiring Requirements

• Bachelor's degree or advanced degree (where required)

• 0-2 years of experience in related field.

• In lieu of degree, 3+ years of experience in related field.


About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at:
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at if you require reasonable accommodation. 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $25.77/daily.