G&A Specialists II (Hybrid, Must live in Mississippi)

Job Summary :

The Grievance & Appeals Specialist II reviews appeals submitted by Medicaid and Medicare providers and all future providers contracted with CareSource. This is a hybrid role and works a few days in our Ridgeland Mississippi office.

Essential Functions :

• Prepare the appeals for clinical review and be responsible for recording and tracking on a regular basis
• Review submitted appeals daily for validation of the appeal
• Identify appropriate claim problem within the appeal
• Prepare all clinical edit appeals for review by computer research, print claim from Facets system, and print off all the code descriptions to assist the reviewer in decision making for committee meetings
• Attend and participate in Appeals Committee meetings as needed
• Maintain spreadsheet of all appeals reviewed with the outcomes resulting from the Appeals Committee Meetings
• Document within Facets the detailed information as to the outcome of the claim appeal
• Identify System changes, log the ticket and track the resolution
• Complete claim appeal through claim adjustments or letters of denials
• Review claim appeals for possible fraud and abuse and report to SIU
• Research and release claim appeals with other health insurance, notifying the COB unit when there is other insurance
• Process a variety of appeals, including but not limited to : dental appeals, low difficulty appeals, non-clinical appeals - (i.e. tobacco surcharge, etc.), medically frail appeals, RCP appeals, member and provider appeals
• Resolve assigned appeals within regulatory timeframes, achieve departmental quality expectations, and meet daily production requirements
• Identify and log any related issues
• Perform UAT testing when necessary
• Perform any other job related instructions, as requested

Education and Experience :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

Compensation Range :

$36,360.00 - $58,230.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type : Hourly

Competencies :

TrueCare is a Mississippi non-profit, provider-sponsored health plan formed by a coalition of Mississippi hospitals and health systems throughout the state and supported by CareSource's national leadership in quality and operational excellence. TrueCare offers locally based provider services through provider engagement representatives and customer care. Our sole mission is to improve the health of Mississippians by leveraging local physician experience to inform decision-making, aligning incentives, using data more effectively, and reducing friction between the delivery and financing of health care. By doing so, TrueCare will change the way health care is delivered in Mississippi.

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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