Appeals Specialist II

Immediate need for a talented Appeals Specialist II. This is a 06+months contract opportunity with long-term potential and is located in US(REMOTE). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-76923

Pay Range: $22 - $23/hour.  Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Hours: Full time - 40 hours per week 
• Schedule: Monday to Friday, 7:00 am to 3:30 pm CST or 8:00 am to 4:30 pm EST (30 minutes Lunch)
• Monday to Friday, 7:00 am to 4:00 pm CST or 8:00 am to 5:00 pm EST (1 hour Lunch)
• No overtime will be available
• Supports the documentation and processing of appeals, disputes and reconsiderations to ensure they are in accordance with state and National Committee for Quality Assurance (NCQA) requirements.
• Support the team to ensure appeals, disputes and reconsiderations are reviewed and processed timely.
•  Knowledge of appeals, disputes and reconsiderations process preferred.
• Performs data entry to support the tracking, logging, and processing of appeals, disputes and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures.
• Prepares correspondence for appeals, disputes and reconsiderations and maintains documentation files.
• Reviews and investigates appeals, disputes and reconsiderations requests to determine applicable follow up.
• Conducts research needed to evaluate, process, and respond to appeals, disputes and reconsiderations to ensure a timely decision.
• Prepares case files including supporting documentation and determinations needed to review, process, and report the appeals, disputes and reconsiderations.
• Gathers appeals, disputes and reconsiderations data to track and report on trends and final outcomes to team including conducting outreach for an update on statuses, determinations, and explanations.
• Performs other duties as assigned.
• Complies with all policies and standards.
• Pull and evaluate cases from CenPAS and review reconsideration/appeal requests from providers/facilities.
• Modify authorizations.
• Respond to claims/UM.
•  Performance expectations/metrics for this individual and their team:
• Dependent upon the assigned role.
•  What the first day looks like:
• Meet with leaders and start learning system/processes.

Key Requirements and Technology Experience: 

• Key Skills; Data Entry / Typing speed: At least 40 wpm
• Knowledgeable with Claims/Coding
• Knowledgeable with Authorizations
• Utilization Management
• Billing/coding (typically found in medical practices/facilities)
• Claim processing
• Teams/Camera/Huddles and 1:1 with Leadership
• Remote with virtual assistance.
• Required: High School Diploma or equivalent
• Preferred: Bachelor’s Degree
• Licensure:
• Required: N/A
• Preferred: i.e. RN, BSN, LPN, etc.

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy