Employer: Lumeris
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Position:
Appeals Specialist (Remote)
Position Summary:
This position is responsible for reviewing, researching, and resolving appeals as quickly as possible to ensure timeframes are met. Escalates complex appeals as needed and ensures compliance with federal regulatory requirements and policies and procedures.
Job Description:
Primary Responsibilities
- Reviews, evaluates, documents, and tracks appeal documents. Follows request through resolution by established processes and procedures, and within established time standards.
- Creates, composes, and provides quality written responses (applying the appropriate composition, grammar, punctuation, and spelling) to appeals request within established time standards.
- Helps identify areas of improvement for self and the department.
- Prepares case files for Independent Review Entities or other levels of the Appeals process.
- Communicates with members and providers on appeal decisions.
- Performs peer QA of appeal notification letters.
- Ensures compliance with all state and federal regulations (Center for Medicare and Medicaid Services, National Committee for Quality Assurance) and guidelines with day to day activities.
Qualifications
- High School or equivalent
- 1 + years Appeals related experience
- Strong learning agility and enthusiastic about developing new skills
- Ability to interact professionally and maintain confidentiality and high ethical standards
- Ability to multi-task, meet deadlines, and adapt to changing priorities
- Solid oral and written communication skills
- Good computer skills, specifically with Microsoft Word, Excel, PowerPoint, and Outlook
- Solid attention to detail
Working Conditions
- While performing the duties of this job, the employee works in normal office working conditions
- Work weekends and company holidays as needed based on business regulatory requirements
Disclaimer
- The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.