Appeals and Grievance Specialist II \ 29

TalentBurst, Inc.

Irving, TX

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JOB DETAILS

SALARY

$30–$33 Per Hour

SKILLS

Analysis Skills, Centers for Medicare and Medicaid Services (CMS), Current Procedural Terminology (CPT), Customer Support/Service, Health Plan, International Classification of Diseases (ICD), Managed Care, Medicare, Operations Processes, Problem Solving Skills, Process Improvement, Resolve Customer Issues, Trend Analysis

LOCATION

Irving, TX

POSTED

8 days ago

Appeals and Grievance Specialist II \ 29
Shift: 8 AM - 5 PM Monday-Friday
Irving, TX 75039 - ONSITE
Duration: 12+ Weeks

Notes: Submit with proof of education; High school diploma
3 years customer service experience with Managed Care Plans.
2years appeal and grievance experience with Managed Care Plans.

Summary:

This position requires the ability to work independently researching and reviewing inquiries from members and providers. Also requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding. Responsible for reviewing, classifying, researching and resolving member complaints (grievances and/or appeals) and communicating resolution to members or their authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services and TRICARE. Coordinates with pertinent departments to effectuate resolution resulting from grievance and appeals resolution decisions made at the plan level or by independent review entities. Adheres to Client Plan policies and procedures which are based on regulated state and federal policies pertaining to the processing of grievances and appeals. Analyzes grievance and appeals data and develops tracking and trending reports at prescribed frequencies for the explicit purpose of identifying and communicating trended root causes of member and provider dissatisfaction. Recommends process improvements to pertinent departments within the organization in order to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum Medicare STAR ratings.

Responsibilities:

Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests.
Integrate and analyze information from several

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Why TalentBurst?
At TalentBurst, we deliver more than talent, we deliver outcomes. We partner with you to move quickly and connect you to opportunities aligned with your skills and long term growth.

Backed by precision, transparency, and results, we connect top talent with leading organizations through trusted partnerships.

We offer competitive compensation and comprehensive benefits, including medical, dental, vision, and retirement options.

TalentBurst is an equal opportunity employer committed to an inclusive and diverse workforce.

About the Company

TalentBurst, Inc.

For over 20 years, TalentBurst Inc. has been an award-winning provider of cutting-edge Workforce Management Solutions. With a strong commitment to staying ahead in the tech landscape, we pioneer innovative approaches to talent acquisition. Our expertise spans Life Sciences, and Healthcare Staffing, Banking, Financial, IT, and Engineering, as well as Global Employer of Record (EOR), Agent of Record (AOR), State, Local Government and Education (SLED), and IC validation/compliance services. Additionally, our division, TalentProcure, leads the industry with offerings such as High Hazard Payroll, Managed Services, and Vendor on Premise (VOP) solutions.

Due to our prioritization of excellent standards, we are Joint Commission Certified and are a certified Minority Business Enterprise (MBE) in the USA and Canada. Supporting over 130 Fortune 500 companies globally, we excel in navigating the landscape of talent acquisition. In a world of constant change, we embrace developing people-centric solutions that address the unique demands of our clients. Stay connected by visiting our website and following us on social media!

COMPANY SIZE

5,000 to 9,999 employees

INDUSTRY

Staffing/Employment Agencies

FOUNDED

2002

WEBSITE

http://www.talentburst.com/