Gateway Health Llc
Job Description :
This job captures all inbound appeals and grievance requests from providers and/or subscribers. The incumbent assesses the request, conducts all necessary research such as verifying benefit coverage for the patient, denial codes, par or non-par provider status and then creates the case (data entry) in the online processing system. Ensures all accurate information is entered at the onset of the process to ensure adherence to all regulatory compliance requirements and service level agreements. The requests may come via fax or mail and may require checking multiple systems. The incumbent is expected to meet established quality and production standards.
- Obtain requests from provider, member or pharmacy via fax or mail.
- Use multiple software systems and various resource sites to determine the type of request (member or provider appeal).
- Build cases in the online processing system.
- Identify if the submission is additional information received for a current case. When necessary, forward to the responsible analyst.
- Ensure accuracy of data entry to prevent compliance and/or downstream process issues.
- Sort and scan incoming mail, and mail correspondence to members and/or providers.
- Complete outbound calls when additional information is required.
- Identify expedited appeals based on key terms/phrases.
- Save medical information to disk.
- Other duties as assigned.
- 1 year of experience working in the Healthcare Industry
LICENSES AND CERTIFICATIONS
- Oral & Written Communication Skills
- Telephone Skills
- Data Entry
- Microsoft Office Suite (Word, Excel and Outlook)
- Attention to Detail
- Problem Solving & Decision Making
- Healthcare Industry
- Health Insurance
Language (Other than English)
0% – 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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