RN Med Appeals & Grievance Specialist Coordinator

Top Healthcare Company is hiring an RN to work remotely as a Med Appeals & Grievance Specialist Coordinator!

***Must have a current RN License in Arizona or a Compact RN license***

Duties:

- Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business

- Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.

- Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.

- Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.

- Maintain complete and accurate records per department policy.

- Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.

- Demonstrate ability to apply plan policies and procedures effectively.

- Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.

- Attend staff and interdepartmental meetings.

- Participate in continuing education and current developments in the fields of medicine and managed care.

- Maintain all standards in consideration of State, Federal, company and other accreditation requirements.

- Maintain productivity and accuracy goals based on regulatory requirements, accreditation standards, and service level agreements.

- Demonstrate ability to acquire specialized knowledge to complete all types of level one appeals, grievances and corrected claims for local lines of business using appropriate benefit plan booklet, administrative guidelines and policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research and precertification research.

- Articulate to customers a variety of information about the organization's services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, Company programs, and provider networks.

- Adheres to Company brand promise of being a "Trusted Advisor" by walking in the customers shoes including processing work using the principles of easy, effective, emotional

Required Education

- Associate's Degree in a healthcare field of study or Nursing Diploma

2. Required Licenses

- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered

REQUIRED COMPETENCIES

- 1 year Experience in clinical and health insurance or other healthcare related field

1. Required Job Skills

- Intermediate PC proficiency (All Levels)

- Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones (All Levels)

2. Required Professional Competencies

- Maintain confidentiality and privacy

- Advanced clinical knowledge

- Practice interpersonal and active listening skills to achieve customer satisfaction

- Compose a variety of business correspondence

- Interpret and translate policies, procedures, programs and guidelines

- Capable of investigative and analytical research

- Navigate, gather, input and maintain data records in multiple system applications

- Follow and accept instruction and direction

- Establish and maintain working relationships in a collaborative team environment

- Organizational skills with the ability to prioritize tasks and work with multiple priorities under limited time constraints

- Independent and sound judgment with good problem solving skills

PREFERRED COMPETENCIES

1. Preferred Job Skills

- Advanced PC proficiency

- Knowledge of Current CPT, ICD- 9, ICD-10, HCPCS, and DRG coding

2. Preferred Professional Competencies

- Working knowledge of McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies

- Advanced ability to interpret contract language and benefits

3. Preferred Leadership Experience and Competencies

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.