Appeals Associate

Our client is seeking a Appeals Associate to join their team for a possible contract to hire role!

Required Skills & Experience

• Associate degree and 6 months - 1 year claims, customer service, medical office (billing, authorizations and/or patient accounting etc.), health insurance or coding experience. If no degree, High School Diploma and 1-3 years’ claims, customer service, medical office (billing, authorizations and/or patient accounting etc.), health insurance or coding experience 6 years' experience in claims, Healthcare Management and Operations, and/or customer service.
• Must be CPC (Certified Professional Coder).
• Must have high speed internet at home

What You Will Be Doing

Daily Responsibilities

• 99% of this work is computer based
• Work from home, must have high speed internet
• The first 4-6 weeks you will receive thorough training
• Research and investigate all aspects of Provider appeals and grievances, NCDOI, Congressional and/or Department of Justice complaints to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), Provider contract provisions, State and/or Federal requirements, guidelines and/or other mandated requirements (e.g. Thomas Love Settlement), NCQA Standards, Current Procedural Terminology (CPT), ICD-9, and Healthcare Common Procedure Coding System guidelines (HCPCS), as applicable.
• Investigate Provider appeals and grievances and NCDOI, Congressional and/or Department of Justice complaints for all lines of business, excluding FEP, by reviewing applicable resources (i.e. CMP, CMS guidelines, CPT coding guidelines, Reconsideration/Appeal Manual, contract provisions, legislation, management, and/or NCQA requirements.
• Identify, collect, and analyze appropriate documentation from multiple internal systems including claims, customer contract management, benefit booklets, UM systems, coding claim edits, etc. and external sources including pharmaceutical companies, attorneys, providers, Medicare, PBMs, etc.
• Coordinate and draft responses to NCDOI, Congressional and/or DOJ complaints with all Enterprise Departments to ensure timely and accurate resolution.
• Consult and confer with medical directors and other clinical staff to ensure the appropriate decision has been made and the approved outcomes are implemented.
• Review, analyze and make determinations on provider requests for increased payments related to coding and/or bundling issues.
• Communicate findings of analysis and documentation to appropriate committee, benefit administrators and  leadership, as necessary.
• Initiate claim adjustments on individual cases when necessary and follow and track until completion.
• Provide written documentation of case determinations to appellants and/or all involved parties (including but not limited to physicians, attorneys, senators/legislators, employer groups, etc.) in a timely manner as required by regulatory mandates and legislation.
• Audit appeal and grievance files as required by Federal and/or State regulatory agencies and provide feedback, education and training to individual employees to ensure compliance with mandates.
• Audit and oversight of entities where delegation of member and provider appeals exists.
• Identify and take corrective action on appeals or grievances that result from noncompliance of contract provisions, appeal or grievance guidelines, provider contract violations and/or medical policies.
• Stays current with press releases, emails, and other forms of communications relaying initiatives, contracting issues, as well as Plan wide concerns.
• Demonstrates high degree of appropriate knowledge of all areas of the plan.
• Identify and create action plans to educate internal departments on benefit misinterpretation and/or claim payment system errors.
• May handle complaints/grievances as defined by the federal government