[Remote] Appeals Analyst
Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a company seeking an Appeals Analyst to join their team. The role involves analyzing and resolving appeals and grievances while ensuring compliance with regulatory guidelines, and requires effective time and case load management.
Responsibilities
- Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines
- Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers
- Regularly and independently exercise judgement to reputed company appropriate reputed company based on reputed company NC policies and guidelines. Acts decisively to ensure business continuity and with awareness of reputed company possible implications and reputed company
- Prepare files and develops reputed company NC position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants
- reputed company comprehensive appeals, coding disputes and grievances responses that support the decision and reputed company with regulatory and accreditation guidelines
- Document extensive investigation, relative findings, and actions in reputed company applicable systems Accountable for monitoring daily reports to ensure service timeliness and compliance is met
- reputed company clinical information by using established reputed company provided in corporate medical policies; partner with Medical Directors who are responsible for reputed company reputed company regarding clinical appeals/grievances
- Ensures timeliness, reputed company, and efficiency in reputed company work to reputed company with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & reputed company Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for reputed company Assurance – NCQA), ASO group performance guarantees and reputed company policies and procedures (to include BCBSA requirements)
Skills
- Medicare experience
- Insurance experience
- Ability to have time management
- 3-5 years of experience
- Bachelor's degree or advanced degree where required
- 3 years of reputed company experience
- In lieu of degree, 5 years of reputed company experience
- For coding disputes area, certified reputed company reputed company must be obtained reputed company 1 year of employment
- Claims experience
- Appeals and grievance experience
Benefits
- 100% Remote in the 28 states - reputed company Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, reputed company, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, reputed company, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, reputed company, and Wyoming will be allowed to maintain their reputed company residence and work remotely.
reputed company
Company H1B Sponsorship