Appeals Specialist II

We are looking for detail-oriented professionals to manage appeals, disputes, and reconsiderations efficiently.   As an Appeals and Reconsideration Specialist, you will evaluate and process case requests while ensuring all determinations meet state and National Committee for Quality Assurance (NCQA) guidelines. Ideal candidates will bring 1 to 2 years of experience in provider reconsideration and possess a working knowledge of TruCare and Amisys software.   Responsibilities: Document, process, and track appeals, disputes, and reconsiderations to ensure timely decisions and compliance with state and NCQA requirements. Perform data entry to log cases in accordance with established regulatory and accreditation guidelines. Review and investigate requests by conducting necessary research to determine applicable follow-up actions.Prepare case files, supporting documentation, and correspondence for all appeals and disputes. Gather case data to track and report on trends and final outcomes. Conduct outreach to provide updates on case statuses, determinations, and explanations. Required Skills & Qualifications: High School diploma or GED.1–2 years of related experience in provider reconsideration, appeals work, or utilization management. Authorization building experience (Required; candidates without this experience will be disqualified). critical thinking and analytical problem-solving skills. Experience operating within TruCare and Amisys systems is highly preferred. Familiarity with established regulatory appeals and disputes processes.

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

Responsibilities

Document, process, and track appeals, disputes, and reconsiderations to ensure timely decisions and compliance with state and NCQA requirements.
Perform data entry to log cases in accordance with established regulatory and accreditation guidelines.
Review and investigate requests by conducting necessary research to determine applicable follow-up actions.Prepare case files, supporting documentation, and correspondence for all appeals and disputes.
Gather case data to track and report on trends and final outcomes.
Conduct outreach to provide updates on case statuses, determinations, and explanations.

Skills

• Authorization Building
• Utilization Management
• Critical Thinking

Qualifications

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

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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.