Clinical Appeals Analyst

Market leading managed care organization looking for remote Appeals Analyst! Great opportunity, please call us today!

Duties:

Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.

Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers.

Regularly and independently exercise judgement to make appropriate decisions based on policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact.

Prepare files and develops position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants.

Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines.

Document extensive investigation, relative findings, and actions in all applicable systems

Accountable for monitoring daily reports to ensure service timeliness and compliance is met.

Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances.

Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance - NCQA), ASO group performance guarantees and policies and procedures.

Qualifications:

Medicare experience

Insurance experience

Ability to have time management

Claims experience

Appeals and grievance experience

3-5 years of experience

Schedule: M-F 8am-5pm

Long term contract with potential for direct hire based on performance!

Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

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.