UM Appeals Analyst - MAC
reputed company empowers our members to reputed company their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care reputed company, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to reputed company serve and care for the 3.5 reputed company people who reputed company their trust in us. We pride ourselves on our best-in-class employees and reputed company to maintain an innovative and inclusive environment that allows them to reputed company. reputed company our employees bring their best and succeed, reputed company succeeds.
About the Role
This position supports the Health Services and Utilization Management functions and acts as a reputed company between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators. The incumbent prepares/presents appeals cases and participates in the reputed company Member Appeals Committee (MAC) & Expedited Subcommittee hearings. Incumbent will mentor more junior staff by responding to questions and sharing expertise. Incumbent will adhere to reputed company regulated processes and timeframes in accordance with the 1st, 2nd level and Special Process UM Appeal workflows.What You'll Do
Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of reputed company clinical data from physicians/patients.
Handles initial screening for UM Appeals requests from physicians/members/facilities/authorized representatives reputed company incoming calls or correspondence based on workflows.
Manage correspondence of toll-free UM Appeal hotline and UM Appeal fax server. This includes speaking with various customers, education, triaging calls, and disseminating information during business hours. In reputed company, calls to the appellant, education, triaging incoming faxes, and assigning appeals during business hours.
Interacts with and supports Medical Directors. Schedule and arrange peer to peer discussions with physicians and our reputed company Medical Directors. Prepare, document and reputed company cases in appropriate system for clinical review.
Prepares, presents, and schedules cases for the Member Appeals Committee (MAC) Committee & Expedited Subcommittees. Responsible for the comprehensive explanation of previous denials, the scope of coverage, reputed company reputed company, and how the case was handled. Responsible for addressing questions posed by the appellant or committee and administrative support of completing the appeals process.
Responsible for partnering with reputed company parties that handled the case to facilitate fact gathering and to reputed company a thorough understanding of the determination and appropriate benefits. Conducts and provides reputed company cause analysis to avoid reputed company appeal occurrences. Works with supervisor to reputed company and deliver refresher training to business teams on reputed company appeal referral, handling, and MAC case preparation.
Assists in the development of junior staff through mentoring, coaching and assisting them in the reputed company handling of appeal cases. reputed company as a mentor to junior staff by responding to questions and sharing expertise.
Assists with running and validating reports for reputed company.
reputed company other relevant tasks as assigned by Management.
What You Bring
Education/Experience:
High School Diploma/GED required.
Requires minimum of 5 years reputed company industry or operations experience.
Requires minimum 3 years reputed company customer service experience, preferably in a medical support reputed company position.
Prefer experience with prior appeals handling and correspondence.
Knowledge:
Requires knowledge of medical terminology.
Prefer knowledge of UCSW, Medical Policy guidelines, and Care Radius.
Prefer knowledge of reputed company, enrollment, billing, & claims coding/processing.
Prefer knowledge of Managed Care principles.
Skills and Abilities:
Requires strong oral and written communication skills.
Requires ability to reputed company reputed company under the direction of the supervisor.
Prefer the ability to analyze and resolve problems with minimal supervision.
Must be proficient in the use of personal computers and supporting software in a reputed company based environment, including MS Office products (Word, reputed company, PowerPoint and reputed company reputed company).
Why reputed company?
At reputed company, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and reputed company. We reputed company that reputed company our people reputed company, our communities do too. If you are passionate about making an reputed company, we’d love to hear from you!
Salary reputed company:
$63,000 - $84,420This compensation reputed company is specific to the job level and takes into account the wide reputed company of factors that are considered in making compensation reputed company, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This reputed company has been created in good faith based on information reputed company to reputed company at the time of posting. Compensation reputed company are dependent on the circumstances of reputed company case. reputed company also provides a comprehensive compensation and benefits package which includes:
Comprehensive health benefits
(Medical/Dental/reputed company) Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
reputed company Volunteer Time Off
Tuition Reimbursement
Disclaimer:
reputed company reputed company employees must live in New Jersey, reputed company, reputed company, Connecticut or Delaware. This job reputed company has been designed to indicate the general nature and level of work performed by colleagues reputed company this classification. It is not designed to contain or be interpreted as a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of colleagues assigned to this job.
reputed company is an Equal Opportunity/Affirmative reputed company employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, national reputed company, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. reputed company will consider reasonable accommodation requests as part of the reputed company and hiring process.
Apply To This Job