[Hiring] Appeals Specialist II @Mindlance

Role Description

Supports the documentation and processing of appeals, disputes, and reconsiderations to ensure they are in accordance with state and National Committee for Quality Assurance (NCQA) requirements. Support the team to ensure appeals, disputes, and reconsiderations are reviewed and processed timely.

• Performs data entry to support the tracking, logging, and processing of appeals, disputes, and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures.
• Prepares correspondence for appeals, disputes, and reconsiderations and maintains documentation files.
• Reviews and investigates appeals, disputes, and reconsiderations requests to determine applicable follow-up.
• Conducts research needed to evaluate, process, and respond to appeals, disputes, and reconsiderations to ensure a timely decision.
• Prepares case files including supporting documentation and determinations needed to review, process, and report the appeals, disputes, and reconsiderations.
• Gathers appeals, disputes, and reconsiderations data to track and report on trends and final outcomes to the team including conducting outreach for an update on statuses, determinations, and explanations.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• Requires a High School diploma or GED.
• Requires 1 – 2 years of related experience.
• Knowledge of appeals, disputes, and reconsiderations process preferred.

Requirements

• 2 years appeals, claims, authorizations.
• Knowledge with reviewing claims and authorizations, familiar with TruCare, Amisys.
• Must have data entry/typing skills (40 wpm).
• Knowledgeable with claims/coding.
• Knowledgeable with authorizations.

Benefits

• Remote with virtual assistance.
• Teams/Camera/Huddles and 1:1 with Leadership.
• After full training, the performance metric is to complete 50 case reviews each day with a 95% or better overall monthly Quality average.
• The ability to gain knowledge in multiple Health Plans.

Company Description

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.