Title: Appeals Analyst
Duration: 12 months
Shift: M-F 8-5 EST
Location: The role is 100% remote, but candidates need to be from an approved conversion State (Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.)

JOB DESCRIPTION:

Responsibilities:

• Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.
• Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers.
• Regularly and independently exercise judgement to make appropriate decisions based on  policies and guidelines.  Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
• Prepare files and develops  position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants.
• Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines.
• Document extensive investigation, relative findings, and actions in all applicable systems
• Accountable for monitoring daily reports to ensure service timeliness and compliance is met.
• Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances.
• Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance – NCQA), ASO group performance guarantees and policies and procedures (to include  requirements). 

Hiring Requirements:

• Bachelor’s degree or advanced degree where required.
• 3 years of related experience
• In lieu of degree, 5 years of related experience
• For coding disputes area, certified professional coder must be obtained within 1 year of employment.

Top 3-4 Required Skills:

• Medicare experience.
• Insurance experience.
• Ability to have time management.

Nice to have Skills:

• Claims experience.
• Appeals and greivance experience.

Years of Experience:

• 3-5 years of experience.

Industry Specific Experience – required, ideal, necessary? 

• Insurance

What is this role’s main focus for the 1st 90 days?

• Get trained then begin working on the case load, will be working within the grievances team.

Breakdown of Duties/Typical Day:

• Research the grievances requests, Prioritize casework, do reach outs from providers and internal teams, handle the grievance response letters.
• Everyday you have new work routed to you and have 30 days to action on each items. a lot of time management and case load management.        

What does the training look like for this role?

• First two weeks of training is classroom training, learning about Medicare, insurance. Then job shadowing the following week to two weeks of on the job training. 

Do you have screening questions?

• Tell me about a time you had to deal with a difficult customer? 

 
 
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 pay range is $29.10/hr - $31.04/hr.