Appeals Specialist II

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MedReview Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

⚕️ Healthcare Insurance

💸 Finance

Healthcare Insurance • Finance

MedReview Inc. is a leading provider of advanced payment integrity solutions, specializing in healthcare claims. They work with a wide range of clients, including health plans, government agencies, and payors, to reduce unnecessary waste and save billions of dollars. Their team of highly trained physicians, registered nurses, and certified coders conduct thorough clinical and coding reviews to identify inaccuracies in healthcare claims. MedReview employs proprietary algorithms to analyze complex data and detect suspicious payment trends, offering a unique blend of clinical expertise and advanced technology to maximize efficiencies and improve healthcare cost management.

📋 Description

• Assist Appeals leadership with daily administrative work within the department. • Perform research, investigation, and analysis of appeals, grievances, and other types of complaints filed by providers and clients to administer timely resolution. • Perform responsibilities for all aspects of nonclinical appeals and inquiries. • Prepare and disseminate case file for External Reviews and/or State Fair Hearing. • Manage and monitor all appeals from Non-Participating providers. • Independently prepare well written, customized responses to all provider inquiries/complaints that appropriately and completely address the complainant’s issues and are structurally accurate. • Ensure timely review, research, and resolution of appeals, grievances, and complaints within guidelines. • Consult with managers on problem cases and interface with clinical supervisors, account managers, and other personnel in resolving health plan requests or provider inquiries. • Log and track grievances, appeals, and other types of complaints as needed. • Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff. • Consult with subject matter experts and resources available within organization to assist in appeal and complaint resolution. • Make critical decisions regarding research and investigation to appropriately resolve all inquiries. • Serve as a liaison to Appeal Coordinator providing guidance and expertise to ensure timely resolution of cases.

🎯 Requirements

• Associates Degree. Additional years of related experience may be used in place of education requirements • 3+ years’ experience working in the health care industry • Experience in inpatient claims, DRG and High-Cost Outlier claims preferred • Experience in DRG Pricing using WebStrat • Knowledge in claim payment methodology • Good MS Office skills. Particularly Excel • Excellent problem solving and analytical skills required • Ability to manage priorities in a complex environment. Excellent organization and time management skills required • Excellent written and verbal communication skills • Takes initiative to proactively identify and solve problems • Ability to meet strict, time sensitive deadlines • Ability to cope well with ambiguity and stressful situations • Must show patience and the ability to remain calm under pressure in an atmosphere of frequent interruptions.

🏖️ Benefits

• Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents. • 401(k) with Employer Match - Join the team and we will invest in your future • Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays. • Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered. • Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional.