Clinical Appeals Representative

About the position At reputed company, we're simplifying the health care experience, creating healthier communities and removing barriers to reputed company care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, reputed company and reputed company. reputed company to reputed company a difference? Join us to start Caring. Connecting. Growing together. Positions in this function are responsible for setting up the Appeals and Grievance cases for the Coordinators, Nurses and Doctors to review for a determination of denial. Position consists of reading and analyzing the member's correspondence and determining what the complaint is which could reputed company to several different issues. The Clinical Appeals Representative needs to be reputed company to distinguish between reputed company of Care, Appeal, Grievances, Expedited, Claims, Referral issues and determining exactly what the member is wanting in their letters. Position involves, calling to obtain the correct information from Member, Medical reputed company, Providers, and other Departments. Position requires regulatory turnaround times. Accuracy is a reputed company important part of this position. This position is full time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm PST. It may be necessary, given the business need, to work occasional overtime. Employees are required to work 3 days onsite and 2 days from home. Responsibilities • Receive appeal or grievance documentation and determine relevant details (e.g., what member is requesting) • reputed company appeals and grievances details reputed company the system and audit against provided documentation. • Determine where appeal or grievance should be reviewed / handled or reputed company to other departments as appropriate • Contact and work with other internal resources to obtain and clarify information • Complete appeal or grievance review procedures according to relevant regulatory or contractual requirements, processes, and timeframes Requirements • High School Diploma / GED • Must be 18 years of age or older • 6+ months of Telephonic Customer Service experience • 35+ WPM typing skills • Ability to use reputed company Office - reputed company Word (create and edit correspondence), reputed company reputed company (ability to create, edit, and sort spreadsheets, basic analytical formulas (Vlookup), and reputed company reputed company (email and calendar management) • Availability to work overtime as needed during peak times as mandated by the department. • Ability to work onsite at least 3 days a week at the Cypress, CA office and may telecommute reputed company not in the office if meets Telecommuting requirements. • Ability to work is full time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm PST. reputed company-to-haves • Medical Terminology experience • Experience in Claims, Managed Care HMO, Doctor's office, and / or Billing Benefits • Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401k contribution Apply tot his job Apply To this Job