The team is responsible for clinically reviewing member appeals and grievances resulting from preservice, post service, or claim denials. In this role, you will perform first-level appeal reviews for members using the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, and nationally recognized sources such as MCG, NCCN, and ACOG. Reviews will also be conducted for medical necessity and to ensure the criteria for the coding billed are met. The ideal candidate will have previous insurance experience, hold at least a Bachelor's Degree in Nursing, and higher-level certifications are highly desirable.
Required Skills (Top 3 Non-Negotiables):
- Knowledge of Medicare benefits and appeal reviews
- Requires 2-4 years of health insurance or related experience
- Demonstrate the ability to act independently using sound clinical judgement
Preferred Skills (Nice to Have):
- Works well in a fast-paced team environment
- Excellent communication skills
