Grievance & Appeals Specialist II

Job Summary:

The Grievance & Appeals Specialist II reviews appeals submitted by Medicaid and Medicare providers and all future providers contracted with CareSource.

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Essential Functions:

• Prepare the appeals for clinical review and be responsible for recording and tracking on a regular basis
• Review submitted appeals daily for validation of the appeal
• Identify appropriate claim problem within the appeal
• Prepare all clinical edit appeals for review by computer research, print claim from Facets system, and print off all the code descriptions to assist the reviewer in decision making for committee meetings
• Attend and participate in Appeals Committee meetings as needed
• Maintain spreadsheet of all appeals reviewed with the outcomes resulting from the Appeals Committee Meetings
• Document within Facets the detailed information as to the outcome of the claim appeal
• Identify System changes, log the ticket and track the resolution
• Complete claim appeal through claim adjustments or letters of denials
• Review claim appeals for possible fraud and abuse and report to SIU
• Research and release claim appeals with other health insurance, notifying the COB unit when there is other insurance
• Process a variety of appeals, including but not limited to: dental appeals, low difficulty appeals, non-clinical appeals – (i.e. tobacco surcharge, etc.), medically frail appeals, RCP appeals, member and provider appeals
• Resolve assigned appeals within regulatory timeframes, achieve departmental quality expectations, and meet daily production requirements
• Identify and log any related issues
• Perform UAT testing when necessary
• Perform any other job related instructions, as requested

Education and Experience:

• High school diploma or equivalent is required
• Associates Degree or equivalent years of relevant work experience preferred
• Minimum of two (2) years of healthcare customer service, claims, compliance or related experience is required

Competencies, Knowledge and Skills:

• Technical writing skills
• Intermediate level skills in Microsoft Word & Excel with Access skills a plus
• Communication skills (written, oral and interpersonal)
• Multitasking ability
• Able to work independently and within a team environment
• Familiarity of the Healthcare field
• Knowledge of Medicaid
• Time Management
• Decision-making and/or problem solving skills
• Proper grammar skills
• Phone etiquette skills

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

$40,400.00 - $64,700.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Hourly

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.