| Story Behind the Need |
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
| - The role of the Triage team is to investigate reconsiderations and claim disputes for the following reasons: To verify if prior authorization was required for the services rendered. To verify if an authorization is on file, and if said authorization was built correctly per the Auth Guidelines and loaded to Amisys with applicable information (dates of service, units, procedure code, provider, etc.). To review the attachments for extenuating circumstances, market specific nuances, service specific nuances, and/or provider specific nuances. To verify medical records are present for claims needing medical necessity review. Triage will document in their pulse note what Auth Builders need to do and why. Failure to do this creates negative impacts on Auth Builders and the Resolution team. Triage is the first line of defense.
- The Utilization Management Shared Services team is a collaborative, high-performing group that thrives on accuracy, accountability, and partnership. Our culture centers on teamwork, open communication, and professional growth. Each team member plays a vital role in ensuring quality reviews, timely case resolution, and compliance with both internal and state-specific guidelines. We foster a supportive environment where questions are welcomed, feedback is encouraged, and success is shared. Team members consistently demonstrate strong attention to detail and take pride in maintaining service excellence across multiple lines of business, including Medicaid and Ambetter. Our work environment is fast-paced and results-driven, yet balanced by a culture of respect, transparency, and continuous improvement. The team collaborates daily across multiple systems; TruCare, CenPAS, Amisys.
- Backfill for FTE and business growth and waiting on 1 more backfill to be approved (Not VSP related)
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| Typical Day in the Role |
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
| Day-to-Day Responsibilities:
The Appeal Specialist II reviews claims in the Corp-BSO Triage Needed basket in CenPAS to determine authorization requirements, validate existing authorizations, and make necessary authorization updates. The role evaluates claims for medical necessity review eligibility, verifies timely filing and required documentation, and documents findings and next steps for Authorization Builders. Responsibilities also include collaborating with internal teams, ensuring accurate case routing, meeting turnaround time standards, and supporting process improvement efforts.
Project Description :
The Triage Team serves as the first line of review for reconsiderations and claim disputes, focusing on validating authorization requirements, reviewing supporting documentation, and ensuring cases are processed accurately before being routed to the Claims Department or Authorization Build Team. The goal of this initiative is to improve workflow efficiency, reduce rework, and support timely, accurate, and compliant claim processing through strong attention to detail and effective cross-team collaboration.
Cases per day 50 6.25 cases per hour (once trained)
No phones no contact with providers or members
Receiving cases through CenPAS
APPLICATIONS - Teams, outlook, excel, word, OneNote, internet browser, Centene applications.
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| Candidate Requirements |
| Education/Certification | Required: High school Diploma or GED | Preferred: |
| Licensure | Required: No | Preferred: |
Years of experience required: 1-2 years prior auth, auth review, behavioral health experience, claims processing and disputes and reconsiderations. UM experience
Disqualifiers: - Lack of demonstrated critical thinking and problem-solving skills.
- Lack of experience or knowledge in claims processing, authorization resolution/disputes, claims reconsiderations, or related healthcare operations.
- Most recent work experience is not in a related field.
- Frequent job changes without clear explanation (please identify contract positions and whether assignments were completed).
- Limited attention to detail or inability to accurately review and process complex case information.
- Lack of experience working across multiple systems and applications in a fast-paced production environment.
Additional qualities to look for: |
- Top 3 must-have hard skills stack-ranked by importance
| 1 | Claims & Authorization Experience/ UM- Strong understanding of claims processing, prior authorizations, disputes, reconsiderations, and healthcare operations.
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| 2 | Critical Thinking & Problem-Solving- Ability to research claims, identify gaps, interpret guidelines, and determine the appropriate next steps with minimal direction.
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| 3 | Attention to Detail & Technical Proficiency- Ability to accurately review complex case information while navigating multiple systems simultaneously. Strong computer literacy, typing skills, and reliable internet connectivity are required.
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| Candidate Review & Selection |
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
| Projected Manager Candidate Review Date: | 24 48 hours interviews set post shortlisting |
Type of Interviews:
| Teams CAMERA ON |
| Required Testing or Assessment (by Vendor): | Typing test 40 WPM 95% accuracy
Computer literacy test
AGENCIES please attach separate docs from the resume. |
| Next Steps |
- Do you have any upcoming PTO?
| None right now but will be sure to have calendar up to date |
- Colleagues to cc/delegate
| Jennifer Cornelius (interview & delegate)
Lynnette R. Moore (interview) |