Grievance & Appeals Specialist III

This is a fully remote position, open to applicants in United States.

📋 Description

• Handle and address claim appeals and disputes.

• Offer expertise in clinical and code edit denials.

• Review, validate, prepare, track, document, and resolve appeals and grievances from both members and providers.

• Prepare clinical edit appeals for assessment utilizing computer research, Facets, claim records, and code descriptions.

• Maintain spreadsheets and documentation regarding appeal outcomes.

• Identify necessary system changes, log support tickets, and monitor resolutions.

• Complete claim appeals through adjustments or denial letters.

• Collaborate with Medical Management, Provider Operations, Provider Service Center, and claims departments.

• Examine appeals for potential fraud and abuse and report findings to Program Integrity.

• Investigate appeals involving other health insurance and inform the COB unit.

• Conduct secondary-level clinical and coding reviews for medical necessity and appropriate reimbursement.

• Analyze unlisted and by-report codes to determine suitable reimbursement.

• Adhere to timeliness, accuracy, quality, and daily production benchmarks.

• Interpret medical procedures, terminology, and notes.

• Prepare for and engage in Non-Clinical State Fair Hearings.

• Execute external review and IRE processes for non-clinical requests.

• Provide escalated effectuation support.

• Investigate Recoupment and Arbitration appeals.

• Assist Customer Care Specialists and Grievance & Appeals Specialists.

• Help monitor grievance processing, reporting, training, procedure reviews, and workflow updates.

• Track and analyze grievance and appeals data to develop proactive interventions.

• Maintain information and supporting documentation in compliance with state requirements.

• Ensure adherence to HIPAA and state regulations.

• Mentor new employees.

• Research and resolve CTM complaints.

• Address member and provider grievances, corporate escalations, state complaints, and BBB complaints.

• Conduct root cause analysis and related documentation.

• Act as an in-person grievance point of contact.

• Perform UAT testing as needed.

• Execute other job-related tasks as assigned.

⛳️ Requirements

• High school diploma or equivalent is required.

• An associate degree or equivalent experience is preferred.

• A minimum of three (3) years in healthcare customer service, claims, compliance, or related fields.

• At least one (1) year of coding experience.

• Intermediate proficiency in Microsoft Word and Excel; Access skills are a plus.

• Excellent written, verbal, and interpersonal communication abilities.

• Strong attention to detail.

• Capability to work autonomously as well as collaboratively within a team.

• Proficient critical listening and analytical thinking skills.

• Technical writing capabilities.

• Effective time management abilities.

• Proper phone etiquette.

• Customer service-oriented mindset.

• Strong decision-making and problem-solving capabilities.

• Exceptional language skills.

• Ability to compose comprehensive statements with proper grammar and sentence structure.

• Capacity to multitask effectively.

• Certified Medical Coder (CPC, RHIT, or RHIA) preferred.

🏝️ Benefits

• Bonus opportunities linked to both company and individual performance may be available.

• A comprehensive total rewards package.

• Support for total employee well-being.