Strategic Staffing Solutions
STRATEGIC STAFFING SOLUTIONS HAS AN OPENING!
This is a Contract Opportunity with our company that MUST be worked on a W2 Only. No C2C eligibility for this position. Visa Sponsorship is Available! The details are below.
“Beware of scams. S3 never asks for money during its onboarding process.”
Title: Medical Appeals Representative
Contract Length: 6+ months
Location: Baton Rouge, LA
On Site Work
Job ref# 240449
Job Description:
- Ensures the timely review of all medical appeals by performing initial review of incoming appeals requests.
- The early differentiation between expedited appeals and standard appeals is integral in assuring that allowed timeframes are met per PPACA, DOI and URAC guidelines.
- Promotes the flow of medical appeals to appropriate clinical staff by prioritizing, organizing, distributing and tracking medical appeals in appropriate applications/logs.
- This requires proficiency with Microsoft Word, Microsoft Excel, Zip File Manager and Adobe Reader.
- Supports department by performing duties normally assigned to Medical Appeals Specialist when situations warrants assistance due to Appeals volume or a MA Specialist is on leave.
- This involves setting up appeals cases, researching and preparation as well as routing and processing appeals.
- To perform this function, employees need to be proficient with JIVA, Facets, ESI, PA Hub, Provider Portal and Common Query.
- Works with unit personnel regarding compliance with all accreditation guidelines, state and federal mandates pertaining to medical appeals
- Promotes the flow of medical appeals to appropriate clinical staff by prioritizing, organizing, distributing and tracking medical appeals in appropriate applications/logs.
- This requires proficiency with Microsoft Word, Microsoft Excel, Zip File Manager and Adobe Reader.
- Supports department by performing duties normally assigned to Medical Appeals Specialist when situations warrants assistance due to Appeals volume or a MA Specialist is on leave.
- This involves setting up appeals cases, researching and preparation as well as routing and processing appeals.
- To perform this function, employee needs to be proficient with JIVA, Facets, ESI, PA Hub, Provider Portal and Common Query.
- Works with unit personal regarding compliance with all accreditation guidelines, state and federal mandates pertaining to medical appeals
Requirements:
- High School Diploma or equivalent is required
- Experience with Facets is PREFERRED not required.: “3 years of insurance experience which includes benefits and claims research is required. Knowledge of Facets application highly preferred”
- 2 years of experience in a customer service and/or claims processing environment is required
- Experience can run concurrently.
- Must be able to read and interpret health benefits for all lines of business.
- Requires thorough knowledge of the claims process and adjustment procedures.
- Must be familiar with CPT, ICD10 and HCPCS coding systems.
- Must have knowledge and understanding of accreditation guidelines, state laws, and internal claims systems.
- Advanced knowledge of Microsoft Office applications Word, Excel, etc. are required.
- Strong organizational and prioritization skills are needed.
- Requires attention to detail and strong record-keeping skills.
- Demonstrated ability to work in a rapidly paced and ever-changing environment is required.
- Facets and JIVA software proficiency is preferred.
- Knowledge of Adobe Reader, Zip File Manager, ESI, PA Hub, Provider Portal and related department software preferred
- Requires proficiency in scanning, printing, faxing capabilities
Duties:
- Retrieves, sorts, compiles and distributes various documents including but not limited to; daily mail, faxes, and departmental reports and uploads into JIVA system.
- Reviews all reports and correspondence to verify appeals meets medical appeals criteria and rates appeals by priority for unit personal to insure attention is given to expedited and urgent appeals first.
- Efficiently and accurately identifies expedited medical appeals requests by utilizing pre-set guidelines to review incoming data; mail, faxes, and e-mail. Sets up cases in JIVA, coordinates urgent and routine scanning and appropriately routing to medical appeals analyst or clinical staff for review. Alerts staff when expedited appeals are received for prompt attention.
- Reviews cases and accurately utilizes JIVA software to create, monitor and finalize all medical appeals ensuring appropriate notification and communication to members and providers, data retention and claims adjudication. After setting up cases in JIVA, will forward to Specialist for further research.
- Supports department by performing duties assigned to Medical Appeals Specialist when situations warrants assistance due to Appeals volume or a MA Specialist is on leave. This involves knowledge on setting up appeals cases, researching and preparation as well as routing and processing appeals same as Medical Appeals Specialist on an as needed basis.
- Ensures proper work flow to enable the department to maintain compliance with relevant department policies and procedures, regulatory agencies and mandated state and federal regulations.
Job ID: JOB-240449
Publish Date: 27 Feb 2025