The CSI Companies is actively seeking a Client Services Representative for our Fortune 10 Healthcare client located in Charleston, WV area.
All The Details:
Great Hours: Mon- Fri 8:00AM to 5:00PM
Located in: Charleston, WV 25301
The Client Services Specialist researches and audits complaints and appeals for the Resolution Teams. Experience in Medicaid/Medicare is preferred for this role as well as experience in complaints/appeals.
- Investigate all data used in making audit determinations and act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures.
- Expert at researching standard plan design and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial.
- Expert at researching various systems to verify accuracy of claim payment, member eligibility data, and billing/payment status.
- Fairly evaluates rebuttals at the first level review, using documented workflows/policies.
- Identifies trends and emerging issues and reports on and gives input on potential solutions.
- Understands and can audit all resolution teams including, executive complaints and appeals, department of insurance, department of health, or attorney general and state complaints or appeals on behalf of members or providers.
- Verifiable high school diploma or equivalent
- Experience in Medicaid and Medicare required
- 1-3 years’ experience in a complaint and appeal team preferred
- Minimum of 1 year work experience in applicant patient areas including but not limited claim handling, products, compliance and regulatory analysis
- Experience in reading and researching benefit language and provider contracts a plus