MedReview Inc. helps payors identify inaccurate medical claims to save millions in overpayments.
Appeals Specialist II
Location
United States
Posted
2 hours ago
Salary
$50K - $55K / year
Seniority
Senior
Job Description
Appeals Specialist II
MedReview Inc.
• Assist Appeals leadership with daily administrative work within the department. • Perform research, investigation, and analysis of appeals, grievances, and other types of complaints filed by providers and clients to administer timely resolution. • Perform responsibilities for all aspects of nonclinical appeals and inquiries. • Prepare and disseminate case file for External Reviews and/or State Fair Hearing. • Manage and monitor all appeals from Non-Participating providers. • Independently prepare well written, customized responses to all provider inquiries/complaints that appropriately and completely address the complainant’s issues and are structurally accurate. • Ensure timely review, research, and resolution of appeals, grievances, and complaints within guidelines. • Consult with managers on problem cases and interface with clinical supervisors, account managers, and other personnel in resolving health plan requests or provider inquiries. • Log and track grievances, appeals, and other types of complaints as needed. • Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff. • Consult with subject matter experts and resources available within organization to assist in appeal and complaint resolution. • Make critical decisions regarding research and investigation to appropriately resolve all inquiries. • Serve as a liaison to Appeal Coordinator providing guidance and expertise to ensure timely resolution of cases.
Job Requirements
- Associates Degree. Additional years of related experience may be used in place of education requirements
- 3+ years’ experience working in the health care industry
- Experience in inpatient claims, DRG and High-Cost Outlier claims preferred
- Experience in DRG Pricing using WebStrat
- Knowledge in claim payment methodology
- Good MS Office skills. Particularly Excel
- Excellent problem solving and analytical skills required
- Ability to manage priorities in a complex environment. Excellent organization and time management skills required
- Excellent written and verbal communication skills
- Takes initiative to proactively identify and solve problems
- Ability to meet strict, time sensitive deadlines
- Ability to cope well with ambiguity and stressful situations
- Must show patience and the ability to remain calm under pressure in an atmosphere of frequent interruptions.
Benefits
- Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents.
- 401(k) with Employer Match - Join the team and we will invest in your future
- Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays.
- Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered.
- Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional.
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