Grievance & Appeals Specialist III

Job not on LinkedIn

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $47.4k - $76k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Process and respond to claim appeals and disputes • Provide subject matter expertise in clinical and code edit denials • Review, validate, prepare, track, document, and resolve member and provider appeals and grievances • Prepare clinical edit appeals for review using computer research, Facets, claim records, and code descriptions • Maintain spreadsheets and documentation of appeal outcomes • Identify system changes, log tickets, and track resolutions • Complete claim appeals through claim adjustments or denial letters • Collaborate with Medical Management, Provider Operation, Provider Service Center, and claims departments • Review appeals for potential fraud and abuse and report to Program Integrity • Research appeals involving other health insurance and notify the COB unit • Perform secondary-level clinical and coding reviews for medical necessity and accurate reimbursement • Analyze unlisted and by-report codes to determine appropriate reimbursement • Meet timeliness, accuracy, quality, and daily production standards • Interpret medical procedures, terminology, and medical notes • Prepare for and participate in Non Clinical State Fair Hearings • Conduct external review and IRE processes for non-clinical requests • Provide escalated effectuation support • Investigate Recoupment and Arbitration appeals • Support Customer Care Specialists and Grievance & Appeals Specialists • Assist with monitoring grievance processing, reporting, training, procedure reviews, and workflow updates • Track and trend grievance and appeals data and develop proactive interventions • Maintain information and supporting documentation according to state requirements • Ensure HIPAA and state requirements and regulations are followed • Mentor new staff • Research and resolve CTM complaints • Resolve member and provider grievances, corporate escalations, state complaints, and BBB complaints • Perform root cause analysis and associated documentation • Serve as an in-person grievance point of contact • Perform UAT testing when necessary • Perform other job-related duties as requested

🎯 Requirements

• High school diploma or equivalent required • Associate degree or equivalent years of relevant work experience preferred • Minimum of three (3) years of healthcare customer service, claims, compliance or related experience • One (1) year of coding experience • Intermediate Microsoft Word and Excel skills; Access skills a plus • Strong written, oral, and interpersonal communication skills • Attention to detail • Ability to work independently and within a team environment • Critical listening and thinking skills • Technical writing skills • Time management skills • Proper phone etiquette • Customer service orientation • Decision-making and problem-solving skills • Strong language skills • Ability to write comprehensive statements using proper grammar and sentence structure • Ability to multitask • Certified Medical Coder (CPC, RHIT or RHIA) preferred

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support

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