Appeals Specialist II

The Appeal Specialist II will manage cases returned from clinicians to the Resolution queues in TruCare after clinical review completion. This role is responsible for reviewing the outcome in TruCare and documenting clear payment or denial instructions in CenPAS through a Pulse Note, based on the authorization or appeal status. The coordinator will also review cases routed with the reason “Corp UM In Clinical Review” to determine if a clinician failed to send the task or if the case remains pending clinical review. Daily responsibilities include collaborating with internal partners, ensuring accurate case routing, maintaining compliance with turnaround time standards, and supporting process improvement initiatives. Years of experience required: 1-2 years prior auth, referrals, claims resolutions and disputes and reconsiderations. UM experience. Top 3 must-have hard skills stack-ranked by importance 1 Knowledge of Prior Authorizations / UM  2 Knowledge of Claims Resolution & Disputes / Claims Reconsiderations   3 Multi-tasking skills (multiple systems at once), literate, computer knowledge, typing skills / internet speed a MUST

salary: $22.99 - $23 per hour
shift: First
work hours: 8 AM - 5 PM
education: High School

Responsibilities

The Appeal Specialist II will manage cases returned from clinicians to the Resolution queues in TruCare after clinical review completion.
This role is responsible for reviewing the outcome in TruCare and documenting clear payment or denial instructions in CenPAS through a Pulse Note, based on the authorization or appeal status.
The coordinator will also review cases routed with the reason “Corp UM In Clinical Review” to determine if a clinician failed to send the task or if the case remains pending clinical review.
Daily responsibilities include collaborating with internal partners, ensuring accurate case routing, maintaining compliance with turnaround time standards, and supporting process improvement initiatives.

Skills

• Prior Authorizations
• Claims Resolution
• Multi-tasking

Qualifications

• Years of experience: 1 year
• Experience level: Experienced

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At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact View email address on randstadusa.com.

Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).

This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.