Job Description

Job Description

Job Description

Job Title: SCA Appeal Rep 1

Duration: 6–9-month contract position

Location….Remote- Must be within a 10–20-mile radius of

Indianapolis, IN
Denison, TX
Baltimore, MD
Harrisburg, PA
Syracuse, NY
Portland, ME
Hingham, MA

Detailed Job Description – highlight 3-5 Must Haves

This job is only to be used if covered under SCA. This is an entry level position in the Appeals Department that reviews, analyzes and processes non-complex pre-service and post service grievances and appeals requests from customer types (i.e., member, provider, regulatory and third party) and multiple products (Part A & B) related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.

Primary duties may include, but are not limited to: Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.

Utilizes guidelines and review tools to conduct extensive research, analyze the grievance, and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review. The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements. As such, the analyst will strictly follow department guidelines and tools to conduct their reviews.

Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination. Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Requires a High school diploma or GED; up to 2 years’ experience working in grievances and appeals, claims, or customer service, familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, all of the company's internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background.

Excellent writing skills. Strong analytical skills. Able to make decisions and work independently. Able to work from home efficiently. Health insurance claims and/or appeals experience preferred.

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