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Appeals Resolution Specialist

AGEATIA TECHNOLOGY CONSULTANCY SERVICES INC.
Washington, DC
  • Expired: over a month ago. Applications are no longer accepted.
Job Description

PURPOSE:
The Appeals Resolution Specialist supports the Provider Appeals Team Lead in the investigation, coordination and resolution of all provider reconsiderations and liens. This role ensures that these issues are resolved within the required timeframes in accordance with client policy.
 
PRINCIPAL ACCOUNTABILITIES:
For provider reconsiderations: Investigates issue, researches and collects all information necessary to resolve the reconsideration.
• Communicates both verbally and in writing with Providers and other departments, to resolve the provider reconsiderations.
• Generates all correspondence (i.e. acknowledgment and resolution letters) to providers as required to comply with all relevant rules, regulations, and policies.
• Requests, collects and logs all supporting documentation and related data including, but not limited to medical records, prior authorizations, member and/or practitioner/provider statements, claims, medical groups; maintains computer-based records and history of each case for liens.
• Accurately maintains the reconsideration database to track and ensure compliance throughout the investigation process.
• Ensures that letters used comply with required guidelines and timeframes.
• Responsible for subrogation activities including the identification and research of subrogation claims.
• Researches paid claims, answers inquiries, and coordinates with other departments, insurance adjustors, attorneys, and members.
• Collaborates with the General Counsel to prepare and submit all related documentation for Fair Hearings, external audits, client position statement preparation.
• Performs other duties of a similar nature and level as assigned, including assisting with overflow of provider appeals.
 
NECESSARY QUALIFICATIONS:
Required Experience/Skills/Abilities:
• A minimum of two (2) years of provider appeals handling experience.
• Experience working with health care benefits or DC Medicaid.
• Principles and practices of the managed health care systems, and medical administration and NCQA Accreditation standards.
• Exercise exceptional judgment in decision-making, meet deadlines, and to work independently and with flexibility.
• Problem solving skills.
• Experience with Facility and Professional audits of claims.
• Knowledge of ICD-10 and HCPC codes, Client, and eligibility tools.
• Proficient in Microsoft Office tools (Word, Excel, PowerPoint).
• Understanding of the claim processing system.
 
Preferred:
• Managed Care experience preferred.
• MHC preferred.

 

Company Description
Ageatia was built on the principle of becoming a leading provider of workforce solutions for clients and candidates across the Engineering, Healthcare, Scientific and Information Technology industries. As we grow and evolve, we recognize our differentiation lies not just in traditional staffing, but in true partnerships and collaboration on hiring solutions.

We bring value to our talent by helping them identify their individual skills and aptitudes, matching them with opportunities to excel and creating communities where they can foster their skills and always have a trusted partner in their career.

In supporting our clients, we understand that each organization and culture is unique, and we thrive in collaborating with our clients to provide innovative solutions to suit their specific needs.

The root of our growth and continued success stems from not only our loyal clients and talent, but the dedication of our people. Ageatia takes great pride in our teammates and the culture we built together as an organization. We promote an environment that rewards the hard work and perseverance necessary to solve the unique needs of our clients and talent. The Ageatia family might span across the country, but our team is tightly united around our core purpose, core values and our mission to provide superior service to our customers.

AGEATIA TECHNOLOGY CONSULTANCY SERVICES INC.

Why Work Here?
Excellent because we work closely with clients to define requirements so that our solution offers solid business value.

Ageatia was built on the principle of becoming a leading provider of workforce solutions for clients and candidates across the Engineering, Healthcare, Scientific and Information Technology industries. As we grow and evolve, we recognize our differentiation lies not just in traditional staffing, but in true partnerships and collaboration on hiring solutions. We bring value to our talent by helping them identify their individual skills and aptitudes, matching them with opportunities to excel and creating communities where they can foster their skills and always have a trusted partner in their career. In supporting our clients, we understand that each organization and culture is unique, and we thrive in collaborating with our clients to provide innovative solutions to suit their specific needs. The root of our growth and continued success stems from not only our loyal clients and talent, but the dedication of our people. Ageatia takes great pride in our teammates and the culture we built together as an organization. We promote an environment that rewards the hard work and perseverance necessary to solve the unique needs of our clients and talent. The Ageatia family might span across the country, but our team is tightly united around our core purpose, core values and our mission to provide superior service to our customers.

Address

Washington, DC
USA

Industry

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