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Mfy4q76dl778yt0586s

Quality Appeals Specialist

KEPRO Raleigh Full-Time
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KEPRO is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting. KEPRO is seeking resumes for a highly experienced professional.

Accountabilities 

  • Support development and maintenance of business processes related to mediation and appeals processes.
  • Verify adverse decision notifications were handled and documented, per protocol.
  • Coordinate with the Officer of Administrative Hearings and mediator in scheduling and conducting mediations and appeals.
  • Track scheduling, decisions, dates and outcomes related to the appeal in the appropriate databases.
  • Support clinical staff with scheduling to attend and preparing their testimony for mediations and appeals.
  • Schedule follow-up assessments for clinical staff related to a reassessment.
  • Prepare and disseminate mailed correspondence.
  • Other duties as assigned.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

Qualifications 

  • Associates degree required.

Knowledge, Skills, Abilities 

  • Excellent verbal and written communication skills.
  • Highly organized.
  • Basic data entry skills.
  • Excellent customer service skills.
  • Ability to meet departmental standards.
  • Must be able to review and prepare case mediation and appeal documentation.
  • Must be able to research and resolve decisions, outcomes of mediations and appeals.

Experience 

  • Requires minimum 3-5 years’ customer service experience.
  • Previous experience in the health care industry preferred.

Mental and Physical Requirements               

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

KEPRO offers challenging careers, excellent benefits and opportunities for advancement.  For consideration, please submit resume and cover letter with salary requirements. Only those candidates identified for an interview will be contacted. No Phone Calls Please.  Visit our website at URL blocked - click to apply for more information on the KEPRO Family of Companies.   

EOE AA M/F/Vet/Disability

KEPRO is an E-Verify employer. E-Verify is an internet based system operated by the Department of Homeland Security (DHS) in partnership with the Social Security Administration (SSA) that allows participating employers to electronically verify the employment eligibility of their newly hired employees in the United States.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.

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$69K
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Job ID: QUALI02114-00001

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Since 1985, KEPRO has helped more than 20 million members lead healthier lives through clinical expertise, integrity and compassion. KEPRO was founded by physicians and clinical expertise is at the core of our organization.

We are a leading quality improvement and care management organization. We offer innovative and outcomes-focused solutions to reduce the unnecessary use of health care resources and optimize the quality of care for public and commercial clients. KEPRO’s tailored programs maximize members’ quality of life, and realize greater cost savings for members and clients alike.

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