100% Remote in the 28 states - North Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming will be allowed to maintain their current residence and work remotely.
Screening questions
Tell me about a time you had to deal with a difficult customer?
Required Skills: Medicare experience, Insurance experience, ability to have time management
Nice to have Skills: claims experience, appeals and greivance experience
Years of Experience: 3-5 years of experience
Interview Process: Video - 3-5 questions- 30 minutes is typical
Two interviewers one round 30 minutes Sherita and team leader
Responsibilities:
" Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.
" Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers.
" Regularly and independently exercise judgement to make appropriate decisions based on Client NC policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
" Prepare files and develops Client NC position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants.
" Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines.
" Document extensive investigation, relative findings, and actions in all applicable systems
Accountable for monitoring daily reports to ensure service timeliness and compliance is met.
" Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances.
" Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance NCQA), ASO group performance guarantees and BCBSNC policies and procedures (to include BCBSA requirements).
Hiring Requirements:
Bachelor s degree or advanced degree where required.
3 years of related experience
In lieu of degree, 5 years of related experience
For coding disputes area, certified professional coder must be obtained within 1 year of employment.
EEO:
Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.