Grievance & Appeals Dispute Specialist
4 weeks ago
Summary of Position
We are seeking a dynamic Grievance and Appeals Dispute Specialist who will be responsible for processing disputes submitted by contracted and non-contracted providers. The types of correspondence handled by the individual will include, but is not limited to; correspondence, HQSI/ESMSEF appeals and Cotiviti disputes. This individual will provide technical and administrative support to Grievance and Appeals dept. to ensure that departmental goals are met.
Roles and Responsibilities:
- Facilitate the dispute review: submit appeal packet via UPS or dispute agent portal, as applicable.
- Intake disputes and compile “dispute” packets for submission to either the DRA agent or Cotiviti
- Review new dispute receipts to confirm request is valid and to identify the appropriate dispute agent. If request is invalid, notify the provider in writing with the reasons why the request is not valid.
- Prepare disputes for external review, reviewing the previous appeal files as applicable and compiling all applicable documents to create the dispute packet.
- Receive dispute decision, updating all applicable systems and notifying delegates as applicable
- Review decision to confirm accuracy and append to the system
- Document decisions in CAG; notify the Sr. Medical Clerk (SMC) to update the care management system as applicable.
- If decision is overturned, the Dispute Specialist will reach out to claims to facilitate the effectuation of the decision.
- Ensure timeframes are met and files are completed per G&A operational policies and procedures.
- Monitor daily and weekly pending reports and CAG work list to ensure timely submission of files.
- Classify/code CAG inquiries appropriately, entering all actions taken in investigation for auditing & reporting purposes.
- Liaison with Claims to ensure determinations are effectuated within stringent timeframes.
- Regular attendance is an essential function of the job.
- Perform other duties as assigned or required.
Qualifications:
- Associates degree
- Additional experience/specialized training may be considered in lieu of educational requirements required
- 1 - 2+ years’ relevant, professional work experience required
- Ability to work under pressure and deliver accurate and timely results required
- Excellent communications skills (verbal, written, interpersonal) required
- Working knowledge of Health Insurance processes required
- Proficient with MS Office (Word, Excel, Powerpoint, Teams, Outlook, etc.) required
- Excellent organizational, problem solving and analytical skills required
Additional Information
- Job Type: Standard
- Schedule: Full-time
- Employee Status: Regular
- Requisition ID: 1000001823
- Hiring Range: $37,000-$65,000
-
Grievance & Appeals Specialist
7 days ago
Farmington, United States EmblemHealth Full timeSummary of Position We are seeking a talented Grievance & Appeals Specialist who will be responsible for responding to written/verbal grievances, complaints, appeals, and disputes submitted by members and providers in accordance with NCQA, CMS, State, and other regulations. They will process appeals and grievances to facilitate the accurate administration of...
-
Product Marketing Specialist
2 weeks ago
Farmington, United States LoanPro Full timeProduct Marketing Specialist Job Ad LoanPro is a Fintech SaaS company, providing core lending infrastructure (software and cloud configuration) to mid-market and large lenders. Our market leading product enables clients to be more efficient, organized, and streamlined in the lending business. LoanPro's software manages over 18 billion dollars in loans, with...
-
Product Marketing Specialist
2 days ago
Farmington, United States LoanPro Full timeProduct Marketing Specialist Job Ad LoanPro is a Fintech SaaS company, providing core lending infrastructure (software and cloud configuration) to mid-market and large lenders. Our market leading product enables clients to be more efficient, organized, and streamlined in the lending business. LoanPro's software manages over 18 billion dollars in loans, with...
-
Product Marketing Specialist
1 week ago
Farmington, United States LoanPro Full timeProduct Marketing Specialist Job Ad LoanPro is a Fintech SaaS company, providing core lending infrastructure (software and cloud configuration) to mid-market and large lenders. Our market leading product enables clients to be more efficient, organized, and streamlined in the lending business. LoanPro's software manages over 18 billion dollars in loans, with...
-
Global Funds Transfer Wire Investigation Associate
2 months ago
Farmington, United States Comerica Bank Full timeJob Description Global Funds Transfer Wire Investigation Associate The Global Funds Transfer Wire Investigator uses analytical skills to independently research, process and resolve investigation cases. Investigations include disputed transactions and processing errors related wire transfers. Position Competencies Successful incumbents possess...
-
Product Marketing Specialist
2 weeks ago
Farmington, United States LoanPro Full timeJob DescriptionJob DescriptionSalary: Product Marketing Specialist Job AdLoanPro is a Fintech SaaS company, providing core lending infrastructure (software and cloud configuration) to mid-market and large lenders. Our market leading product enables clients to be more efficient, organized, and streamlined in the lending business. LoanPro’s software manages...
-
Human Resources Manager
3 weeks ago
Farmington, United States NAVAJO PREPARATORY SCHOOL , INC. Full timePURPOSE OF POSITION The Human Resource Manager guides and manages the overall provision of Human Resources services under the direction of the Division Director of Business and Human Services, policies, and programs for the School and provides technical advice in all areas of human resources administration, labor relations, training programs, and compliance...
-
Human Resources Manager
2 days ago
Farmington, United States NAVAJO PREPARATORY SCHOOL , INC. Full timePURPOSE OF POSITION The Human Resource Manager guides and manages the overall provision of Human Resources services under the direction of the Division Director of Business and Human Services, policies, and programs for the School and provides technical advice in all areas of human resources administration, labor relations, training programs, and compliance...
-
Human Resources Manager
3 weeks ago
Farmington, United States Navajo Preparatory School Inc Full timeJob DescriptionJob DescriptionPURPOSE OF POSITIONThe Human Resource Manager guides and manages the overall provision of Human Resources services under the direction of the Division Director of Business and Human Services, policies, and programs for the School and provides technical advice in all areas of human resources administration, labor relations,...
-
Human Resources Manager
1 day ago
Farmington, United States Navajo Preparatory School Inc Full timeJob DescriptionJob DescriptionPURPOSE OF POSITIONThe Human Resource Manager guides and manages the overall provision of Human Resources services under the direction of the Division Director of Business and Human Services, policies, and programs for the School and provides technical advice in all areas of human resources administration, labor relations,...
-
Automotive Parts Specialist
1 day ago
Farmington, United States LaFontaine Volvo Cars of Farmington Hills Full timeJob DescriptionJob DescriptionJob Description:AUTOMOTIVE PARTS SPECIALIST Are you interested in joining a growing business that is committed to family, promotes employees from within, is passionate about protecting the environment, has an inspiring company culture, and is actively involved with the community and local charities? If so, this opportunity might...
-
Automotive Parts Specialist
2 weeks ago
Farmington, United States LaFontaine Volvo Cars of Farmington Hills Full timeJob Description Job Description Job Description: AUTOMOTIVE PARTS SPECIALIST Are you interested in joining a growing business that is committed to family, promotes employees from within, is passionate about protecting the environment, has an inspiring company culture, and is actively involved with the community and local charities? If so, this opportunity...
-
Medical Billing AR Specialist
2 weeks ago
Farmington, United States M.I.N.D Full timeJob DescriptionJob DescriptionJob Description – Medical Billing AR SpecialistClassification – FSLA - Non-Exempt - hourlySalary Grade/Level/RangeLevel of experience, longevity, within current company pay structure.Reports toRevenue Cycle ManagerSummary/ObjectiveMedical Billing AR Specialists perform analysis of patient clinical and billing data to...
-
Community Connector
1 month ago
Farmington, United States Molina Healthcare Full timeJOB DESCRIPTION Candidate must reside in the State of New Mexico Job Summary Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. ...
-
Debit Card Specialist
5 days ago
Farmington, United States Community Choice Credit Union Full timeJob DescriptionJob DescriptionPurpose & Core Values The primary purpose of any position is to assist Community Choice Credit Union to live out our purpose: we believe in helping our neighbors achieve the life they desire. A key component of this purpose is to provide outstanding service to both internal and external members by living our core values....
-
Debit Card Specialist
1 day ago
Farmington, United States Community Choice Credit Union Full timeJob DescriptionJob DescriptionPurpose & Core Values The primary purpose of any position is to assist Community Choice Credit Union to live out our purpose: we believe in helping our neighbors achieve the life they desire. A key component of this purpose is to provide outstanding service to both internal and external members by living our core values....
-
Collections Specialist
17 hours ago
Farmington, United States Hartford Healthcare Full timeDescription Job Schedule: Full Time Standard Hours: 40 Job Shift: Shift 1 Shift Details: Hybrid Position. Home base in Farmington, CT. Work where every moment matters. Every day, over 38,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of...
-
Full Time Hospitalist Physician
2 weeks ago
Farmington, Michigan, United States VISTA Staffing Solutions, Inc. Full timeVISTA's Permanent Placement Division presents an opportunity for a non-profit, community-owned organization that is looking for a BE/BC Internal Medicine/Family Medicine Hospitalist.Benefits of this long-term position:Practice Advantages:Inpatient roleEmployed by a diverse medical groupAverage of 16 patients per shiftHybrid block scheduling (16 shifts...
-
Full Time Hospitalist Physician
1 day ago
Farmington, Michigan, United States VISTA Staffing Solutions, Inc. Full timeVISTA's Permanent Placement Division presents an opportunity for a non-profit, community-owned organization that is looking for a BE/BC Internal Medicine/Family Medicine Hospitalist.Benefits of this long-term position:Practice Advantages:Inpatient roleEmployed by a diverse medical groupAverage of 16 patients per shiftHybrid block scheduling (16 shifts...
-
Pediatric Hospitalist, Neurology
1 month ago
Farmington, United States Connecticut Children's Medical Center Full timeSUMMARY The Pediatric Hospitalist is accountable for delivering comprehensive quality patient care, including diagnostic and interventions according to standards of practice for children from birth through adolescence. The incumbent functions as a member of an inter-disciplinary team within an integrated academic model, with the potential for a clinical...