Job Description

JOB SUMMARY:

THE APPEALS AND GRIEVANCES ANALYST – PROVIDER DISPUTES POSITION WILL ENSURE THAT BRIGHT HEALTH RESPONDS TO PROVIDER PAYMENT DISPUTES IN A TIMELY, PROFESSIONAL, AND CUSTOMER-FOCUSED MANNER, AND COMPLETED ACCORDING TO STATE AND FEDERAL REGULATORY STANDARDS. THIS POSITION WILL BE RESPONSIBLE FOR RESOLUTION OF ASSIGNED CASES, ACCURATE AND TIMELY DOCUMENTATION OF CASE ACTIONS, AND ASSIST IN THE OVERSIGHT OF DELEGATES RESPONSIBLE FOR APPEALS AND GRIEVANCES FUNCTIONS.

RESPONSIBILITIES:

THE APPEALS AND GRIEVANCES ANALYST – PROVIDER DISPUTES DESCRIPTION IS INTENDED TO POINT OUT MAJOR RESPONSIBILITIES WITHIN THE ROLE, BUT IT IS NOT LIMITED TO THESE ITEMS.

1. REVIEWS AND RESEARCHES PROVIDER PAYMENT DISPUTE CASES AND FOLLOWS UP TO ENSURE THAT RESOLUTION HAS OCCURRED, DOCUMENTATION IS COMPLETE, REQUIRED TIMEFRAMES ARE MET, AND PROPER WRITTEN COMMUNICATION OF THE DECISION HAS OCCURRED. IN MOST CASES, PREPARE THE WRITTEN COMMUNICATION OF THE DECISION IN PLAIN WRITTEN LANGUAGE. COORDINATES ADDITIONAL FOLLOW UP ACTIVITIES WITH APPROPRIATE DEPARTMENT MANAGERS AND/OR LEADS AND TRACKS TO CONCLUSION.

2. MAINTAINS PROVIDER PAYMENT DISPUTE CASE FILES AND INCLUDES NECESSARY INFORMATION TO LOG INCOMING CORRESPONDENCES, TRACKING DISPOSITIONS, AND MAINTAINING TIMELINESS OF RESOLUTION AS REQUIRED BY STATE AND FEDERAL MANDATES.

3. ENSURES THAT ALL INFORMATION TO MEMBERS, PROVIDERS, OTHER PARTIES-TO-A-COMPLAINT, AND OTHER APPROPRIATE PERSONS IS ACCURATE, CONSISTENT, AND CUSTOMER SENSITIVE.

4. PARTICIPATES IN INTERNAL COMMITTEE AND INTERDISCIPLINARY MEETINGS, REPORTING RECENT ACTIVITY AND ANALYSIS OF TRENDS, AND MAKES RECOMMENDATIONS FOR PROBLEM RESOLUTION AND PERFORMANCE IMPROVEMENT

5. MONITOR ALL INCOMING PROVIDER PAYMENT DISPUTE CHANNELS INCLUDING MAIL, FAX AND PHONE

6. OTHER DUTIES AND RESPONSIBILITIES AS ASSIGNED

EDUCATION:

• BACHELOR’S DEGREE OR EQUIVALENT WORK EXPERIENCE PREFERRED

• THREE (3) OR MORE YEARS OF EXPERIENCE IN HEALTH PLAN OPERATIONS SETTING REQUIRED, PREFERABLY IN APPEALS & GRIEVANCES, PROVIDER DISPUTES, CLAIMS OR HEALTH CARE CUSTOMER SERVICE

• EXPERIENCE IN VARIOUS CLAIM PRICING METHODOLOGIES.

• CERTIFIED CLAIM CODER PREFERRED

PROFESSIONAL COMPETENCIES:

• DETAIL ORIENTED

• THRIVE IN FAST-PACED ENVIRONMENTS AND HAVE A PASSION FOR EXTEMPORARY CUSTOMER SERVICE AND RESOLVING CONFLICTS

• SELF-DIRECTED, ABLE TO PRIORITIZE AND TAKES OWNERSHIP IN PROJECTS, CASES, AND WORKGROUPS

ABOUT MEDIX?

MEDIX IS DEDICATED TO POSITIVELY IMPACTING LIVES EVERY DAY. SINCE 2001, WE HAVE MADE IT OUR MISSION TO BE THE LEADING PROVIDER OF WORKFORCE SOLUTIONS FOR CLIENTS AND CANDIDATES ACROSS THE HEALTHCARE, SCIENTIFIC, AND INFORMATION TECHNOLOGY INDUSTRIES.

OUR DEDICATED RECRUITERS ARE HERE TO HELP YOU FIND AND SECURE JUST THE RIGHT OPPORTUNITY. WE TAKE THE TIME TO LEARN ABOUT YOU, YOUR SKILLS, YOUR INTERESTS, AND YOUR CAREER GOALS, AND THEN MATCH YOU WITH THE JOBS AND COMPANIES THAT BEST SUIT YOUR NEEDS. WHETHER YOU ARE LOOKING FOR A CONTRACT, CONTRACT-TO-HIRE, OR DIRECT HIRE POSITIONS, WE CAN HELP YOU TO FIND THE MEANINGFUL AND GRATIFYING WORK THAT YOU'VE BEEN LOOKING FOR. LET MEDIX BE YOUR PARTNER AS YOU MOVE YOUR CAREER FORWARD. CONTACT US TODAY!

BENEFITS

ONCE YOU HAVE BEEN A CONTRACT EMPLOYEE OF MEDIX FOR 30 DAYS, YOU BECOME ELIGIBLE FOR OUR BENEFITS PROGRAM. SHOULD YOU ELECT TO ENROLL, THERE ARE THREE LEVELS OF MEDICAL COVERAGE TO CHOOSE FROM, SUPPLEMENTAL DENTAL PLANS AND TERM PLANS AS WELL AS THE OPTION TO ENROLL YOUR SPOUSE AND/OR CHILDREN. YOU CAN SELECT THE BEST COMBINATION THAT BEST SUITS YOUR NEEDS.

AS A CONTRACT EMPLOYEE WITH MEDIX, YOU CAN CHOOSE TO ENROLL IN OUR BENEFITS PROGRAM DURING YOUR ELIGIBILITY PERIOD AND ENJOY:

● MINIMUM ESSENTIAL COVERAGE (MEC) PLAN

● TWO DIFFERENT FIXED INDEMNITY PLAN ADD-ONS

● MAJOR MEDICAL PLANS, INCLUDING 1 HSA PLAN

● DENTAL

● VISION

● SHORT-TERM DISABILITY

● LIFE AND AD&D

THIS YEAR’S RECIPIENT OF THE BUSINESS LEDGER'S "ENTREPRENEURIAL EXCELLENCE GROWTH AWARD"

JOIN OUR NETWORK OF TALENTED PROFESSIONALS

Company Description

Medix is a company fiercely dedicated to positively impacting lives and businesses with talent solutions backed by people data and industry expertise. CORE PURPOSE: To bring opportunities to businesses and job seekers that positively impact lives. At Medix, we boldly and decisively put people ahead of everything. Why? Because when you make the right choices for people, purpose is clear and performance and profits follow. Every day we positively impact the lives of our talent, clients, internal team and communities by: Ensuring every person can thrive at work, placing them in roles that match their skills and aspirations Knowing what matters most to clients, from skills to culture, to deliver workforce solutions that fuel productivity and success Building a purpose-driven, values-led workplace where employees are empowered to do good and deliver their best work Giving back in numerous ways to strengthen the communities we serve.