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Role Description

This role involves managing all activities associated with requests for Provider Billing Disputes and Appeals.

• Analyze, prepare, and evaluate prior determinations
• Coordinate clinical review if needed
• Make decisions and provide notifications
• Follow guidelines outlined by contracts, company documents, and regulatory requirements
• Provide information and assistance to members, providers, and other stakeholders regarding benefits and claims
• Access licensed health professionals for clinical reviews

Do you have a passion for serving others and learning new things? Do you thrive as part of a collaborative, caring team? Then this role may be the perfect fit.

Qualifications

• High school diploma or GED required
• Minimum 4 years' experience in Customer Service, Claims, or Clinical Services, or equivalent combination of education and work experience
• Coding Certification (CPC, CCS, or similar) preferred

• Excellent verbal and written communication skills
• Intermediate computer skills including Microsoft Word, Excel, and Outlook
• Knowledge of medical terminology, anatomy, and coding systems (CPT, DX, HCPCs)
• Demonstrated initiative and analytical ability
• Ability to listen and communicate appropriately
• Ability to switch tasks and prioritize work effectively
• Experience with AI tools and technologies to enhance productivity is highly desired

Requirements

• Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal
• Review claim coding, claim processing history, medical policy, reimbursement policies, and legal requirements
• Make non-clinical appeal determinations as permitted by department business processes
• Oversee set-up of appeals for external review organizations
• Provide information, education, and assistance to members and providers
• Track appeals in appropriate systems and assist in maintenance of files
• Support, apply, and promote Provider or Member Appeal Policies and Procedures

Benefits

• Medical, dental and vision coverage for employees and their eligible family members
• Annual employer contribution to a health savings account
• Generous paid time off and 10 company-paid holidays
• Market-leading retirement plan including a company match on employee 401(k) contributions
• Up to 12 weeks of paid parental time off
• Award-winning wellness programs
• Employee Assistance Fund for those in need
• Commute and parking benefits