Employment Requirements
This opportunity is not open to C2C relationships or visa sponsorship.
This opportunity is for local candidates only.
Job Description
Perform analysis and research of requests received for medical grievances, appeals for final resolution or referral to the Clinical Medical Appeals and Grievance (MAG) Staff.
Responsibilities
- Maintains advanced end user knowledge of multiple systems including vendor medical management and claims systems
- Conduct research to resolve requests received from members, providers and other Blue Plans in accordance with State, Federal, BlueCard and URAC timeliness standards.
- Review medical records to determine if records satisfy the requested or supporting information required.
- Complete specific Appeals and Grievances after clinical training.
- Maintain current medical terminology knowledge.
- Identify research and assemble medical records, coverage guidelines, claims and historical data for MAG staff review and presentation to the Medical Director, Department of Insurance, Executive Inquiries or other legal proceedings.
- Perform data corrections and initiate adjustments related to appeals originating from the Medical Grievance and Appeals Department. Communicate decisions through appropriate system updates.
- Analyze and monitor appeals, grievances, and insufficient records to identify possible trends or patterns and document and report findings to Supervisor and/or Manager with suggestions and follow-up.
Qualifications
- 1 years of experience in claims processing, medical/ pharmacy precertification, appeals and grievances coordination or other applicable related work experience(Applies to All Levels)
Required Education
- High-School Diploma (Applies to All Levels) or higher
Preferred Qualifications
- 2 years of experience in a lead or senior claims role (Applies to All Levels)
- 3 years of experience in claims processing and correspondence with multiple claims systems (All Levels)
- 2 years of experience in the medical or healthcare related field (Applies to All Levels)
- 3 years as a pharmacy technician or precertification technician
Preferred Education
- Bachelor’s degree in business/healthcare or related field
Preferred Certifications
Additional Information
Position is remote and through the end of 12/31/26 with possible extension
