Job Title - Appeals Processing Representative
Pay Range - $16.55/ Per hour
Hour: Monday- Friday (8-4:30 but a little flexible)
Location - Bedford, TX - 76021
Responsible for handling member and provider appeals/complaints involving medical necessity, retroactive authorizations, prescription drug coverage, and/or member eligibility. Responsible for tracking and reporting performance against HHSC guidelines. May complete intake, initialize the case for processing, and ensure cases are completed in a quality, organized, and timely fashion.
- Responsible for intake of appeals/complaint unit mail, sorting, and distributing within required timeframes.
- Responsible for date stamping and properly identifying request type and region. Utilizes appropriate system to research required documentation for case work up.
- Responsible for determining the appropriate type of response to a requested appeal or complaint.
- Must determine deadline dates on all cases and ensure they are met or exceeded.
- Contacts parties to obtain missing/outstanding information for processing and completion.
- Prepares all correspondence to gather and investigate a case.
- Obtains waivers of liability (WOL), authorization of representative (AOR), and medical records requests.
- Refers cases to other departments to gather information to complete the investigation.
- Maintains tracking and monitoring information on a database and software used in the department.
- Provides tracking and trending reports to departmental leadership on the root causes of appeals and complaints and the high volume appellants.
- Responds to Expedited and Provider Claim appeals.
- Keeps current with all requirements of STAR+PLUS plan appeals and complaints.
- Provides training to peers as necessary in case handling.
- Enters all job related activities in the applicable database
- Comprehensive knowledge in STAR+PLUS Appeals and Complaints and experience in managed care
- Strong analytical skills, ability to formulate, write reports and professional correspondence
- Knowledge of regulations and statutory language and interpretation
- Understanding of the claims, membership and health services systems
- Strong sense of customer service.
- Exceptional written communication skills.
- Strong interpersonal skills including tact, diplomacy, and flexibility to work effectively with senior administration, staff and the general public.
- High School Diploma or Equivalent
- Knowledge and Proficiency with Microsoft Office
- Strong data entry skills
Medix is dedicated to positively impacting lives every day. Since 2001, we have made it our mission to be the leading provider of workforce solutions for clients and candidates across the Healthcare, Scientific, and Information Technology industries.
Our dedicated recruiters are here to help you find and secure just the right opportunity. We take the time to learn about you, your skills, your interests, and your career goals, and then match you with the jobs and companies that best suit your needs. Whether you are looking for contract, contract-to-hire, or direct hire positions, we can help you to find the meaningful and gratifying work that you've been looking for. Let Medix be your partner as you move your career forward. Contact us today!
Once you have been a contract employee of Medix for 30 days, you become eligible for our Benefits Program. Should you elect to enroll, there are three levels of medical coverage to choose from, supplemental dental plans and term plans as well as the option to enroll your spouse and/or children. You can select the best combination that best suits your needs.
As a contract employee with Medix, you can choose to enroll in our Benefits Program during your eligibility period and enjoy:
Minimum Essential Coverage (MEC) plan
Two different fixed indemnity plan add-ons
Major Medical Plans, including 1 HSA Plan
Life and AD&D
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