Appeals Resolution Analyst

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Oversee the complete appeals process, which includes receiving appeals, inputting data into the medical management system, coordinating external vendor reviews, and ensuring timely case completions.

• Communicate with providers and members regarding the appeal process and the status of their appeals.

• Manage and prioritize the appeal Hotline phone queue.

• Work together with both internal and external vendors to handle appeals in compliance with NCQA, DOBI, State, and other regulatory requirements.

• Adjust authorizations based on the outcomes of appeals and guarantee timely claim processing.

• Coordinate with internal stakeholders to ensure they are informed of appeal outcomes.

• Conduct testing and engage in projects to achieve departmental objectives.

• Resolve basic clinical appeals for Government Programs under supervision while adhering to timeliness and accuracy standards.

⛳️ Requirements

• A High School diploma or GED is required.

• A Bachelor's degree from an accredited institution is preferred.

• At least one (1) year of recent acute care medical-surgical or rehabilitation experience is preferred.

• One (1) year of experience in utilization management is preferred.

• Knowledge of healthcare delivery systems is required.

• Familiarity with CPT-4 and ICD-9 coding is necessary.

• Understanding of medical terminology is required.

• Experience in healthcare insurance is preferred.

• Strong oral and written communication skills are essential.

• Strong analytical and logical thinking abilities are required.

• Proficient use of grammar, diction, and articulation is expected.

• Ability to type at least 25 wpm is preferred.

• Familiarity with Current Medical Management Systems is preferred.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement