Job description

100% remote.

Responsible for the analysis, research, and completion of complex non-contracted provider Medicare appeal investigations. Effectively administer all steps of the non-contracted provider appeal to thoroughly investigate appeal requests, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaborating to resolve issues whenever possible. Ensure compliance with all mandated, legislative, regulatory, and accreditation requirements. Assist customers and staff throughout the process by providing complete information and following up on a timely basis

The Appeals Analyst makes decisions on moderately complex issues regarding the technical approach for project components, and work is performed without direction. Exercises latitude in determining objectives and approaches to assignments.

Essential Functions

Responsible for a complex and thorough investigation of Medicare appeals from a non-contracted provider which may include: gathering all relevant information for the appeal request (external medical records, internal documentation from enterprise-wide systems including claims payments, billing and enrollment, care management, medical, pharmacy and behavioral health authorizations, customer service interactions, prescription claims, medical policies, and plan documents)

Resolve appeals timely per CMS guidelines; when appropriate, including collaboration internally with all levels within the organization

Analyze and investigate requests for submission to the Independent Review Entity ( IRE) which may include: gathering relevant information and preparing comprehensive documentation as 'evidence'. Ensure timely submission of documentation.

Track all activity including communication for each appeal case by entering complete documentation of issues and related follow-up

Requirements

• Required Associate's Degree or equivalent
• Preferred Bachelor's Degree or equivalent
• 5 years of relevant experience Grievance & or Appeal Analyst or related experience Required
• 3 years of relevant experience Member or Provider Customer service, Claims, Legal and/or enrollment/eligibility Preferred
• Extensive knowledge of managed care products and regulatory and accreditation requirements; Maintain knowledge of policies and procedures, including medical policies which may impact the grievance, appeal, and review processes Preferred

Job Types: Full-time, Contract

Pay: $20.00 - $22.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Vision insurance

Schedule:

• Monday to Friday

Application Question(s):

• Will you now, or in the future, require sponsorship for employment visa status (e.g., H-1B visa status)?

Work Location: Remote

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