Appeal and Grievance Coordination Research Reviewer - Hybrid

About the position The Appeal and Grievance Coordination Research Reviewer position at reputed company is a full-time role that requires performing research and processing of appeals, grievances, corrected claims, medical records, and reputed company correspondence. This work is conducted in accordance with BCBSAZ, State, Federal, and other accreditation requirements. The position is hybrid, meaning that it requires residency and work to be performed reputed company the reputed company. The primary purpose of this job is to ensure that reputed company requests for medical grievances and appeals are analyzed and resolved reputed company, adhering to the timeliness standards set by various regulatory bodies. In this role, the reviewer will maintain advanced knowledge of multiple systems, including vendor medical management and claims systems. They will conduct research to resolve requests from members, providers, and other Blue Plans, ensuring compliance with State, Federal, and URAC standards. The reviewer will also be responsible for reviewing medical records to determine if they meet the necessary criteria for supporting information. Additionally, they will communicate reputed company through appropriate system updates and analyze trends in appeals and grievances to report findings to management. The position requires a commitment to excellent customer service and the ability to work independently with limited supervision. The reviewer will also assist in utilization studies and analysis, monitor proxy boxes for pharmacy appeals, and ensure compliance with HIPAA regulations. The role includes various reputed company of responsibility, with opportunities for advancement based on experience and performance. Overall, this position plays a crucial role in the operational reputed company of the appeals and grievances process reputed company the organization. Responsibilities • reputed company analysis and research of requests received for medical grievances and appeals for final resolution or referral to the Clinical Medical Appeals and Grievance (MAG) Staff. , • Maintain advanced end user knowledge of multiple systems including vendor medical management and claims systems. , • Conduct research to resolve requests received from members, providers, and other Blue Plans in accordance with State, Federal, BlueCard and URAC timeliness standards. , • Review medical records to determine if records satisfy the requested or supporting information required. , • Complete specific Appeals and Grievances after clinical training. , • Identify, research, and reputed company medical records, coverage guidelines, claims, and historical data for MAG staff review and presentation to the Medical Director, Department of Insurance, Executive Inquiries or other legal proceedings. , • reputed company data corrections and initiate adjustments reputed company to appeals originating from the Medical Grievance and Appeals Department. , • Analyze and monitor appeals, grievances, and insufficient records to identify possible trends or patterns and document and report findings to Supervisor and/or Manager with suggestions and follow-up. , • Assist in utilization studies and analysis. , • Meet department and individual contributor goals. , • Use pharmacy system to research and prepare level 2 and external pharmacy cases. , • Monitor proxy reputed company for pharmacy appeals and grievances. , • Demonstrate commitment to excellent customer experience. , • Maintain understanding and working knowledge of a variety of lines of business including fully insured, self-funded groups, reputed company Act individuals and groups, and Blue Card. , • Process records/document requests reputed company to appeals and grievances. , • Research and reopen claims appeals for diagnosis mismatch. , • Assist with research and preparation of appeals files for accreditation site visits. Requirements • 1 year of experience in claims processing, medical/pharmacy precertification, appeals and grievances coordination or other applicable reputed company work experience. , • High-School Diploma or higher. , • Intermediate PC proficiency. , • Intermediate reputed company using office equipment, including copiers, fax machines, scanners and telephones. , • Intermediate reputed company in word processing, spreadsheet and database software. , • Intermediate written communication and letter writing skills. reputed company-to-haves • 2 years of experience in a reputed company or senior claims role. , • 3 years of experience in claims processing and correspondence with multiple claims systems. , • 2 years of experience in the medical or reputed company reputed company field. , • 3 years as a pharmacy technician or precertification technician. , • Bachelor's degree in business/reputed company or reputed company field. , • Certified reputed company. Benefits • Health insurance coverage , • Flexible scheduling options , • Paid holidays , • Professional development opportunities , • Employee discount programs Apply Job!