Appeal and Grievance Coordinator-CW

Wholecare Position

Wholecare position will involve:

• Claims research and processing (more of researching why the claim was denied than actually researching into the claim)
• Authorization lookup/building authorizations as well as updating authorizations
• Researching outside vendor sites for authorizations and review of notes
• Reviewing appeal letters to determine what the provider is appealing
• Responsible for starting the appeal process and researching the appeal. Responsible for sending out appeal determination letters and completing the appeal
• Extensive training on internal and external systems and the internal appeal process

Please have the resource take the Customer Service Assessment (Highmark) in Glider. Candidates that get 8 of the 11 questions right will move towards the top of the list (one of the questions involves typing speed.)

Remote M-F (8-hr shift that will start between 7am -9am) USC CTH unlikely (but possible if a position is open) Pay rate should be between *** ***/hr (FT positions will start around *** ***/hr) Beeline for timesheets Receive, investigate and triage expedited appeal requests received from Highmark members/member and provider representatives enrolled in Senior Products. Timely assignment of cases is critical to ensure member's and/or provider's appeal rights are processed in accordance with regulatory agencies' standards, including the Center for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA).

At least 1 year of experience in health insurance claims and appeals is strongly preferred. At least a HS degree, but a college degree and/or extensive experience would be considered. Outbound call experience (though not a large part of this job) is a good to have. A customer service background and experience, not necessarily in the healthcare field, is a nice to have as well. Medicaid experience desired and will make the candidate stand out. The job receives, researches and correctly classifies all grievance and appeals cases. This includes any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and state and federal regulations set forth for government products.