Appeals Specialist II

Position Summary At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews. Under the direction of the Appeals Department leaders, the Appeals Coordinator level II team member will assist Appeals leadership with daily administrative work within the department. The Appeals Specialist level II performs research, investigation, and analysis of appeals, grievances, and other types of complaints filed by providers and clients to administer timely resolution. Responsible for all aspects of nonclinical appeals and inquiries. Responsibilities This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of the department and NYCHSRO/MedReview in general. 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. Ensures that all complaints are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy Consults with managers on problem cases and interfaces 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. Consults 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 Other duties and responsibilities as assigned Qualifications 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 deadlinesAbility 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 Remote Work Requirements High speed internet (100 Mbps per person recommended) with secured WIFI. A dedicated workspace with minimal interruptions to protect PHI and HIPAA information. Must be able to sit and use a computer keyboard for extended periods of time. Benefits and Perks 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. Salary Range $50,000- $55,000/ annually. #J-18808-Ljbffr