Job Details

Position: Medical Claims/ Appeals Specialist

Location: Denison, TX

Duration: 6 months+ temp-to-hire!!!

Pay rate: $20/hr on W2

Note:

• REMOTE role with possibility
• The schedule for the training period will be a set schedule: 8:00am to 4:30pm EST time.
• Training will be 5-6 weeks. After training, the candidates may choose to flex start time of 6:00 AM EST to 10:00 AM EST.
• Candidates can work from 50 miles (or 1 hour) from any NGS or PulsePoint locations (EXCEPT the state of CA). These are not HYBRID requirements while working temp. However, if/when they convert temp-hire, they must be willing to work onsite depending on what the HYBRID requirements for FTE associates are at the time of conversion (usually 1-3 days per week).

JOB DESCRIPTION:

This is an entry level position in the Appeals Department that reviews, analyzes and processes non-complex pre-service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (Part A & B) related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.

• The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.
• Requires a High school diploma or GED; up to 2 years' experience working in grievances and appeals, claims, or customer service or any combination of education and/or experience which would provide an equivalent background.
• Familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, all of the company's internal business processes, and internal local technology strongly preferred.
• Preferred Skills: Medical Terminology, Letter Writing, Claims Experience, Appeals Experience

Primary duties may include, but are not limited to:

• Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
• Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
• The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements.
• As such, the analyst will strictly follow department guidelines and tools to conduct their reviews. Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
• Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.

I'd love to talk to you if you think this position is right up your alley, and assure a prompt communication, whichever direction.

If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.

Recruiter Name: Gurjant “Gary” Singh

Title: Lead Recruiter

Email: ...@ameritconsulting.com