Remote Appeal and Grievance Coordinator

13666-1 , Remote Appeal and Grievance Coordinator, Pittsburgh, PA - 4+ Months, Contract to hire

Sigma Systems Inc is looking to hire a Appeal and Grievance Coordinator for their client.

Due to the governmental nature of these positions, only US Citizens are eligible to apply.

Shift Details: M-F (8-hr shift that will start between 7am -9am)

Responsibilities:

• Receive, investigate and triage expedited appeal requests received from Client members/member and provider representatives enrolled in Senior Products.
• Timely assignment of cases is critical to ensure member's and/or provider's appeal rights are processed in accordance with regulatory agencies' standards, including the Center for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA).
• Claims research and processing (more of researching why the claim was denied than actually researching into the claim)
• Authorization lookup/ building authorizations as well as updating authorizations
• Researching outside vendor sites for authorizations and review of notes
• Reviewing appeal letters to determine what the provider is appealing
• Responsible for starting the appeal process and researching the appeal. Responsible for sending out appeal determination letters and completing the appeal.
• Extensive training on internal and external systems and the internal appeal process

Requirements:

• At least 1 year of experience in health insurance claims and appeals is strongly preferred
• At least a HS degree, but a college degree and/or extensive experience would be considered.
• Outbound call experience (though not a large part of this job) is a good to have.
• A customer service background and experience, not necessarily in the healthcare field, is a nice to have as well.
• Medicaid experience desired and will make the candidate stand out.
• The job receives, researches and correctly classifies all grievance and appeals cases.
• This includes any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and state and federal regulations set forth for government products.
• Must have prior claims or appeals work history