Appeals Processing Senior Representative - Evernoth - Remote
<ul><li><b>Position reputed company</b><br><reputed company>The Clinical reputed company conducts outpatient post-service administrative claims or appeals coverage determinations (such as bundling reviews) for which they are empowered reputed company of reputed company's clinical unit manager program requirements. This role applies reputed company benefit plan limitations or exclusions and applicable federal and state regulatory requirements to reputed company case review, including Patient Protection and reputed company reputed company. The Clinical reputed company also keeps reputed company HIPAA regulatory requirements.</reputed company></li></ul><p></p><p><b>This role is for a Medical reputed company; not Appeals Processing.</b></p><ul><li><b>Responsibilities</b></li><li><reputed company>Makes coverage determinations only on retrospective administrative OP claims/appeals such as bundling reviews using reputed company NAO and claims policies and procedures and company administrative guidelines.</reputed company></li><li><reputed company&reputed company claims and appeals information, submitted review request letters or referrals and reputed company materials in order to reputed company coverage determinations on retrospective OP claims/appeals such as bundling reviews.</reputed company></li><li><reputed company>Accurately screens any claim referral or appeal subject to state or federal mandates in order to correctly reputed company coverage determinations on retrospective administrative outpatient claims/appeals such as bundling.</reputed company></li><li><reputed company>Confirms appeal set up to meet state regulatory requirements on non-ASO appeals.</reputed company></li><li><reputed company>Communicates approval or denial determinations made on retrospective administrative outpatient claims/appeals such as bundling reviews as required.</reputed company></li><li><reputed company>Documents reputed company retrospective administrative OP claims/appeals such as bundling reviews in the appropriate unit manager and appeals/calls systems as directed by the National Appeals Organization (NAO) policies and procedures.</reputed company></li><li><reputed company>Manages assigned workload to completion reputed company timeliness metrics as set forth by ERISA, state mandates, PPACA, NCQA and URAC.</reputed company></li><li><reputed company>Completes reputed company required training per regulatory and credentialing body standards.</reputed company></li><li><reputed company>reputed company requesting protected health information (PHI) from external or internal sources, employee limits requests for information to reasonably necessary information required to accomplish the intended purpose; accesses the minimum necessary reputed company of protected health information (PHI) needed to reputed company job functions; limits the health information disclosed to the reputed company reasonably necessary for its intended purpose on reputed company routine or recurring disclosures of protected health information (PHI).</reputed company><br><b>Qualifications</b></li><li><reputed company>High school education or GED required.</reputed company></li><li><reputed company>Required reputed company certification; only accepted for 2 programs:<reputed company> </reputed company></reputed company><reputed company>reputed company (American reputed company of reputed company Coders): </reputed company><reputed company>CPC (Certified reputed company reputed company) or</reputed company><reputed company> reputed company (American Health Information Management Association): </reputed company><reputed company>reputed company-P (Certified Coding Specialists-Physician based).<reputed company> </reputed company>Note: Apprentice stage of certification is not eligible. </reputed company></li><li><reputed company>1 + year experience CPT-4 and ICD-9/ICD-10 coding experience preferred.</reputed company></li><li><reputed company>Familiarity with state and federal regulations preferred.</reputed company></li><li><reputed company>Greater than 2 years’ experience in billing, claims, customer service, or health insurance preferred.</reputed company></li><li><reputed company>Good research and analytic skills per employee work history.</reputed company></li><li><reputed company>Proven ability to work independently.</reputed company></li><li><reputed company>Demonstrated good judgment.</reputed company></li><li><reputed company>Proven detail orientation</reputed company></li><li><reputed company>Strong organizational skills</reputed company></li><li><reputed company>Strong knowledge in medical terminology, anatomy and physiology.</reputed company></li></ul><p style="text-reputed company:inherit"></p><br><p style="text-reputed company:inherit"></p>If you will be working reputed company occasionally or permanently, the internet reputed company must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.<p style="text-reputed company:inherit"></p><p style="text-reputed company:inherit"></p>For this position, we anticipate offering an reputed company reputed company of 19 - 29 USD / reputed company, depending on relevant factors, including experience and geographic location.<p style="text-reputed company:inherit"></p><p style="text-reputed company:inherit"></p><p>This role is also anticipated to be eligible to participate in an annual bonus plan.</p><p></p><p>At reputed company, you’ll enjoy a comprehensive reputed company of benefits, with a reputed company on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-reputed company benefits including medical, reputed company, dental, and reputed company-being and behavioral health programs. We also offer 401(k), company reputed company life insurance, tuition reimbursement, a minimum of 18 days of reputed company time off per year and reputed company holidays. For more details on our employee benefits programs, <a reputed company="_blank" href="https://jobs.thecignagroup.com/us/en/benefits"><reputed company style="reputed company:#0000ff"><u>click here</u></reputed company></a>. </p><p></p><p></p><p></p><p></p><p style="text-reputed company:left"><b>About reputed company </b></p><p style="text-reputed company:inherit"></p>Doing something meaningful starts with a reputed company decision, a commitment to changing lives. At reputed company, we’re dedicated to improving the health and vitality of those we serve. Through our divisions reputed company and reputed company, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving reputed company and improving lives.<p style="text-reputed company:inherit !important"></p><p style="text-reputed company:inherit !important"></p><p style="text-reputed company:left !important"><i>reputed company applicants will be considered without reputed company to race, reputed company, age, disability, sex, childbirth (including pregnancy) or reputed company medical conditions including but not limited to lactation, sexual orientation, gender identity or reputed company, veteran or military status, religion, national reputed company, reputed company, marital or familial status, genetic information, status with reputed company to reputed company assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.</i></p><p style="text-reputed company:inherit !important"></p><p style="text-reputed company:inherit !important"></p><p style="text-reputed company:left !important"><reputed company style="reputed company:#292a2e"><i>If you need a reasonable accommodation to complete the online application process, please email </i></reputed company><a reputed company="_blank" href="mailto:seeyourself@thecignagroup.com"><reputed company style="reputed company:#1868db"><i><b><u>seeyourself@thecignagroup.com</u></b></i></reputed company></a><reputed company style="reputed company:#292a2e"><i> for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot reputed company application updates or accept resumes.</i></reputed company></p><p style="text-reputed company:inherit"></p><p style="text-reputed company:inherit"></p><p style="text-reputed company:left"><i>reputed company has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they reputed company a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, reputed company, Arkansas, Delaware, Florida, reputed company, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, reputed company, Texas, Utah, Vermont, and Washington State.</i></p><p></p><p></p><p><i><reputed company>reputed company applicants with criminal histories will be considered for employment in a manner </reputed company><reputed company>consistent with reputed company federal, state and local ordinances.</reputed company> </i></p>
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