Appeals Specialist

at  BCforward

REQUIREMENTS:

• Appeals
• Prior Authorization
• Healthcare Claims
• Medicaid/Medicare

EDUCATION/EXPERIENCE:

Requires a High School diploma or GED.
Requires 1 - 2 years of related experience.
Knowledge of appeals, disputes and reconsiderations process preferred.
Performs data entry to support the tracking, logging, and processing of appeals, disputes, and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures.
Prepares correspondence for appeals, disputes and reconsiderations and maintains documentation files.
Reviews and investigates appeals, disputes, and reconsiderations requests to determine applicable follow up.
Conducts research needed to evaluate, process, and respond to appeals, disputes, and reconsiderations to ensure a timely decision.
Prepares case files including supporting documentation and determinations needed to review, process, and report the appeals, disputes, and reconsiderations.
Gathers appeals, disputes, and reconsiderations data to track and report on trends and final outcomes to team including conducting outreach for an update on statuses, determinations, and explanations.
Performs other duties as assigned.
Complies with all policies and standards.

REQUIRED EXPERIENCE / SKILLS / EDUCATION:

Knowledge of appeals, disputes, and reconsiderations process.
Medical Office Experience.
Prior Authorization building.
Healthcare Claims.
Medicaid/Medicare/Ambetter knowledge.
Healthcare Background.
Medical Assistant.
Excel, Microsoft.

EXPERIENCE

Not Specified

Supports the documentation and processing of appeals, disputes, and reconsiderations to ensure they are in accordance with state and National Committee for Quality Assurance (NCQA) requirements. Support the team to ensure appeals, disputes and reconsiderations are reviewed and processed timely.