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
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other
Industries
IT Services and IT Consulting
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