BusinessOperations - Appeals Specialist II - J00909

Position Purpose:
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.

Education/Experience:
Requires a High School diploma or GED.
Requires 1 2 years of related experience.


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

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.