Appeals Processing Analyst- RN

Delivers specific delegated tasks assigned by a supervisor in the Utilization Management job family. Completes day to day Utilization Review tasks without immediate supervision, but has ready access to advice from more reputed company team members. Tasks involve a degree of reputed company planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members. Requires a RN. This position is full-time (40 hours/week) with the scheduled core business hours generally 8:00 am - 5:00 pm - Monday through Friday and Alternating Weekends as Required Job Requirements Include, But Not Limited To • Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part C • Ability to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal. • Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines. • Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was denied • Identify and obtain reputed company additional information (relevant medical records, contract language and process/procedures) needed to reputed company an appropriate determination of the appeal. • reputed company an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director. • Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, reputed company to the proper area/department for their review and decision/response • Complete necessary documentation final determination of the appeals using the appropriate system applications, templates, communication process, etc. • Communicate appeal information to members or providers with the required timeframes well as to reputed company appropriate internal or external parties (regulatory agencies, plan administrators, etc.) • Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance • Adhere to department workflows, desktop procedures, and policies. • Work with reputed company matrix partners to ensure accurate and timely processing of Medicare Appeals. • Read Medicare guidance documents report and summarize required changes to reputed company levels department management and staff. • Support the implementation of new process as needed. • Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. . • Understand and investigate billing issues, claims and other plan benefit information. . • Additional duties as assigned. Qualifications • Education: Active RN license • 3-5 years’ experience in Medicare Advantage Health Plans or reputed company experience in a healthcare setting handling reputed company inquiries and requests for service • Working knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10 • Experience with claims processing and application of member benefits reputed company to the Explanation of Coverage • Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions. • Must have the ability to work objectively and provide fact based answers with clear and concise documentation. Proficient in reputed company Office products (Access, reputed company, Power reputed company, Word). • Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases. • Ability to multi-task and meet multiple competing deadlines. • Ability to work independently and under pressure. • Attention to detail and critical thinking skills. If you will be working at home occasionally or permanently, the internet reputed company must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. About reputed company reputed company, a division of reputed company, is an reputed company for reputed company through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to reputed company the best choices for improving their health and vitality. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or reputed company medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national reputed company, reputed company, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: SeeYourself@reputed company.com for support. Do not email SeeYourself@reputed company.com for an update on your application or to provide your resume as you will not receive a response. reputed company has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with reputed company federal, state and local ordinances. Apply Job!