Supports the review, research, processing, and resolution of medical and pharmacy appeals and grievances. Conducts investigations, reviews medical records and claims information, maintains regulatory compliance, identifies trends, and provides administrative and analytical support for complex appeals, legal inquiries, audits, and accreditation reviews.
Responsibilities
Research and resolve medical and pharmacy appeals, grievances, and related inquiries from members, providers, and external organizations.
Review medical records, claims, coverage guidelines, historical data, and supporting documentation to determine case resolution.
Process appeals and grievances in accordance with applicable state, federal, regulatory, accreditation, and contractual requirements.
Prepare records, case files, written communications, and supporting documentation for medical directors, legal teams, regulatory agencies, audits, and accreditation reviews.
Process data corrections, initiate claims adjustments, and coordinate resolutions with the appropriate departments.
Research and reopen claims appeals involving diagnosis mismatches.
Use medical management, claims, pharmacy, and other systems to research, document, track, and update cases.
Process Level 1 reviews and support Level 2 and external pharmacy case preparation.
Monitor assigned appeals and grievance communication channels, proxy boxes, and telephone queues.
Identify and report trends in appeals, grievances, insufficient records, and medical documentation to management.
Assist with utilization studies, quality sampling audits, aging reports, case assignments, and related analyses.
Assist with customer inquiries, reviewer questions, training activities, and staff mentoring.
Create job aids and help maintain department procedures and reference materials.
Communicate with vendors, special groups, privacy personnel, and legal teams as directed.
Maintain confidentiality and ensure compliance with HIPAA and protected health information requirements.
Maintain current knowledge of medical terminology, claims processing, business lines, regulatory requirements, appeal timeframes, and grievance procedures.
Complete required and additional training, demonstrate competency, and participate in professional development activities.
Meet department performance goals while working independently with limited supervision and maintaining a commitment to excellent customer service.
Requirements
At least one year of experience in claims processing, medical or pharmacy precertification, appeals and grievances coordination, or a related field.
High school diploma or equivalent required;a higher level of education is acceptable.
Preferred experience includes two years in a lead or senior claims role.
Preferred experience includes three years of claims processing and correspondence using multiple claims systems.
Preferred experience includes two years in a medical or healthcare-related field.
Preferred experience includes three years as a pharmacy technician or precertification technician.
A bachelor's degree in business, healthcare, or a related field is preferred.
Professional certification, such as Certified Coder, is preferred.
Skill
Intermediate computer proficiency and experience using office equipment.
Intermediate proficiency with word processing, spreadsheet, database, claims, medical management, and pharmacy systems.
Strong written communication, correspondence, and letter-writing skills.
Ability to conduct investigative and analytical research.
Ability to interpret and apply policies, procedures, programs, benefits, and administrative guidelines.
Knowledge of claims processing logic and healthcare operations.
Ability to navigate, gather, enter, and maintain information in multiple systems.
Strong interpersonal, active listening, collaboration, and customer service skills.
Ability to maintain confidentiality and protect personal health information.
Ability to establish effective working relationships in a team environment.
Advanced computer, database, spreadsheet, and written communication skills are preferred.
Experience in a lead or senior claims position is preferred.
Summary Qualification
Demonstrated experience reviewing and resolving healthcare claims, appeals, grievances, or precertification requests.
Ability to analyze medical records, claims data, coverage guidelines, and regulatory requirements.
Strong attention to detail, organization, documentation, and follow-through.
Ability to manage confidential information and meet strict processing deadlines.
Effective communication skills for working with members, providers, internal departments, vendors, and regulatory or legal representatives.
Ability to work independently, support team operations, and contribute to quality improvement initiatives.
Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.
Numbers & Facts
Location
Phoenix, AZ
Skills
Administrative Skillsunmatched
Analysis Skillsunmatched
Claims Managementunmatched
Claims Processingunmatched
Communication Skillsunmatched
Compensation and Benefitsunmatched
Computer Skillsunmatched
Contract Requirementsunmatched
Customer Support/Serviceunmatched
Data Processingunmatched
Detail Orientedunmatched
Diversity Recruitingunmatched
Documentationunmatched
Federal Laws and Regulationsunmatched
Follow Throughunmatched
HIPAA (Health Insurance Portability and Accountability Act)unmatched
Healthcareunmatched
Healthcare Softwareunmatched
High School Diplomaunmatched
Information Technology & Information Systemsunmatched
Information/Data Security (InfoSec)unmatched
Interpersonal Skillsunmatched
Legalunmatched
Legal Appealsunmatched
Mail Processingunmatched
Maintain Complianceunmatched
Medical Recordsunmatched
Medical Researchunmatched
Medical Terminologyunmatched
Mentoringunmatched
Nursingunmatched
Office Equipmentunmatched
Operational Supportunmatched
Organizational Skillsunmatched
Pharmacyunmatched
Quality Assuranceunmatched
Quality Managementunmatched
Regulationsunmatched
Regulatory Requirementsunmatched
Spreadsheetsunmatched
Systems Maintenanceunmatched
Team Playerunmatched
Time Managementunmatched
Trend Analysisunmatched
Word Processingunmatched
Writing Skillsunmatched
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