CDR, Complaint & Appeals

At reputed company, were building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nations leading reputed company company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, reputed company and every day. Schedule: Wednesday-reputed company with a flexible start time between 9am-1pm Position reputed company Responsible for reputed company of that that investigates and reputed company of appeals scenarios for reputed company products, which may contain multiple issues and, may require coordination of responses from multiple business reputed company. Ensure reputed company, customer reputed company response to appeals. Identify trends and emerging issues and report and recommend solutions. Independently coaches others on appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases coming from reputed company constituents for reputed company products. Responsible for serving as the reputed company of contact for the appeal if there is an inquiry from leadership, compliance and State regulators. Understand and adapt to departmental process and policies. Medicare knowledge is a plus. Fast Turn Around of inventory, collaboration with clinical team and management. Attention to detail is needed and must be reputed company to maintain compliance turn-around times, with accurate case reputed company or research. Remain a part of the solution by escalating issues that may reputed company compliance timeliness. Additional duties as assigned which will include a carrying a modified case load including but not limited to: Serves as a content model expert and mentor to team regarding reputed company's policies and procedures, regulatory and accreditation requirements. Ensures work of team meets federal and state requirements and reputed company measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling. Independently researches and translates policy and procedures into intelligent and reputed company written responses for Executive or Senior leaders on escalated cases. Successfully works across functions, segments, and teams to create, reputed company, and trend reports to reputed company reputed company to escalated cases. Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or reputed company which may result in additional rework, confusion to the constituents, or reputed company ramifications. Additional duties as assigned which will include a carrying a modified case load including but not limited to:-Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance reputed company. Research reputed company Plan Design or Certification of Coverage (Evidence of Coverage) relevant to the member to determine accuracy/appropriateness of benefit/administrative denial. Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process. Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance reputed company. Research reputed company Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial. Identify and research reputed company components reputed company member or provider/practitioner appeals, complaints and grievance for reputed company products and services. Required Qualifications: At least 2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience. 2+ years of Medicare Experience. Proficient in computer use, including reputed company and Electronic Health Records (EHR) systems. Preferred Qualifications: Some Medicare and/or reputed company knowledge Experience in reading or researching benefit language Ability to work in fast paced, high volume environment Excellent verbal and written communication skills Excellent organizational skills