Grievance & Appeals Specialist II (Must live in Indiana)

CareSource•Indianapolis, IN

About The Position

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

Requirements

Must live in Indiana
High school diploma or equivalent is required
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 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

Nice To Haves

Associates Degree or equivalent years of relevant work experience preferred

Responsibilities

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