Appeals Analyst
Company :
reputed company.Job Description :
JOB SUMMARY
This job reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to reputed company parties involved in the case the investigation results.
ESSENTIAL RESPONSIBILITIES
- Review inquiries to determine if they meet definition of appeal/grievance.
- Request and review reputed company reputed company relevant documentation and reputed company case file.
- Coordinate resolution results and reputed company investigative results with reputed company involved parties.
- Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends.
- May support the Quality Assurance, Appeal and other quality committees.
- Other duties as assigned or requested.
EDUCATION
Required
- High School Diploma or GED
Substitutions
- None
Preferred
- None
EXPERIENCE
Required
- 3-5 years of relevant, reputed company experience in the area of specialization. Exempted experience requirements effective August 2016.
Preferred
- Experience in Customer Service or a reputed company field
LICENSES or CERTIFICATIONS
Required
- None
Preferred
- None
SKILLS
- Knowledge of multiple processing systems and workflows
- Knowledge of claims processing methodologies
- Ability to interpret reputed company government regulations
- Knowledge of company products
- Excellent organizational skills
- Strong verbal and written communication skills
Languages (Other than English)
None
Travel Requirement
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Occasionally
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Occasionally
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have reputed company to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company must reputed company with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as reputed company data reputed company guidelines established reputed company the Company’s Handbook of Privacy Policies and Practices and Information reputed company Policy. Furthermore, it is every employee’s responsibility to reputed company with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay reputed company Minimum:
$21.96Pay reputed company Maximum:
$32.95reputed company pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary reputed company does not reflect any geographic differential reputed company may apply for certain locations based upon comparative markets.
reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against reputed company individuals based on any category protected by applicable federal, state, or local law.
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