Grievance & Appeals Specialist II (Indianapolis Office Hybrid)

2 weeks ago

Indianapolis, Indiana, United States CareSource Full time

Job Summary:

The Grievance & Appeals Specialist II plays a critical role in reviewing appeals submitted by Medicaid and Medicare providers and future providers contracted with CareSource. This position requires strong analytical and communication skills to ensure timely and accurate resolution of appeals.

Key Responsibilities:

  • Prepare appeals for clinical review and track progress.
  • Review submitted appeals daily for validation and identify appropriate claim problems.
  • Prepare clinical edit appeals for review by computer research and attend Appeals Committee meetings as needed.
  • Maintain spreadsheets of appeals reviewed with outcomes and document detailed information in Facets.
  • Identify system changes, log tickets, and track resolutions.
  • Complete claim appeals through adjustments or letters of denial.
  • Review appeals for possible fraud and abuse and report to SIU.
  • Research and release appeals with other health insurance and notify the COB unit.
  • Process a variety of appeals, including dental, low difficulty, non-clinical, medically frail, RCP, member, and provider appeals.
  • Resolve assigned appeals within regulatory timeframes and meet daily production requirements.

Requirements:

  • High school diploma or equivalent required; Associates Degree or equivalent years of relevant work experience preferred.
  • Minimum of two years of healthcare customer service, claims, compliance, or related experience required.

Competencies:

  • Technical writing skills.
  • Intermediate level skills in Microsoft Word & Excel with Access skills a plus.
  • Communication skills (written, oral, and interpersonal).
  • Multitasking ability.
  • Able to work independently and within a team environment.
  • Familiarity with the Healthcare field.
  • Knowledge of Medicaid.
  • Time Management.
  • Decision-making and/or problem-solving skills.
  • Proper grammar skills.
  • Phone etiquette skills.

Working Conditions:

  • General office environment; may be required to sit or stand for extended periods of time.

Compensation Range: $39,000 - $63,400.00. CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level.

Compensation Type: Hourly.

Competencies: Create an Inclusive Environment, Cultivate Partnerships, Develop Self and Others, Drive Execution, Influence Others, Pursue Personal Excellence, Understand the Business.

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