- Prepare appeals for clinical review and record and track them regularly
- Review submitted appeals daily for validation
- Identify the appropriate claim problem within each appeal
- Prepare clinical edit appeals using computer research, Facets claims, and code descriptions for committee review
- Attend and participate in Appeals Committee meetings as needed
- Maintain a spreadsheet of reviewed appeals and committee outcomes
- Document claim appeal outcomes in Facets
- Identify system changes, log tickets, and track resolution
- Complete claim appeals through claim adjustments or denial letters
- Review appeals for possible fraud and abuse and report to SIU
- Research and release appeals involving other health insurance and notify the COB unit
- Process dental, low-difficulty, non-clinical, medically frail, RCP, member, and provider appeals
- Resolve assigned appeals within regulatory timeframes and meet quality and daily production requirements
- Identify and log related issues
- Perform UAT testing when necessary
- Perform other job-related instructions as requested
Requirements
- 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
- Technical writing skills
- Intermediate level skills in Microsoft Word & Excel; 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
- General office environment; may be required to sit or stand for extended periods of time
Demonstrates expertise in preparing and processing clinical appeals, ensuring compliance with regulatory timeframes while maintaining quality standards. Proficient in utilizing Facets for documentation and tracking of appeals outcomes, with strong communication and multitasking abilities.
Highest-signal resume keywords
- Clinical Appeals Preparation
- Facets Claims Management
- Healthcare Customer Service
- Technical Writing Skills
- Knowledge of Medicaid
Hard Skills
- Clinical Appeals Processing
- Facets Documentation
- Microsoft Word
- Microsoft Excel
- UAT Testing
Soft Skills
- Communication Skills
- Multitasking Ability
- Time Management
- Decision-Making Skills
- Interpersonal Skills
Industry Keywords
- Healthcare
- Claims
- Compliance
- Fraud and Abuse
- COB Unit
Tools & Technologies
- Facets
- Microsoft Access
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Grievance & Appeals Specialist II Arbeitgeber: Jobtailor
Als Front Office Supervisor in unserem dynamischen Team bieten wir Ihnen die Möglichkeit, in einem unterstützenden und freundlichen Arbeitsumfeld zu wachsen. Wir legen großen Wert auf die berufliche Entwicklung unserer Mitarbeiter und bieten regelmäßige Schulungen sowie die Chance, Verantwortung zu übernehmen. Unsere Lage ermöglicht es Ihnen, Teil einer lebendigen Gemeinschaft zu sein, während Sie gleichzeitig die Standards unseres Franchise-Partners einhalten und unseren Gästen einen unvergesslichen Aufenthalt bieten.
