Grievance & Appeals Dispute Specialist
EmblemHealthNew York, NY, United States6 days ago
Job type
- Full-time
Job descriptionIntake disputes and compile "dispute" packets for submission to either the DRA agent or Cotiviti. Review new dispute receipts to confirm request is valid and to identify the appropriate dispute agent. If request is invalid, notify the provider in writing with the reasons why the request is not valid. Prepare disputes for external review, reviewing the previous appeal files as applicable and compiling all applicable documents to create the dispute packet. For disputes : receive and / or monitor reports and portals for dispute decisions; update all applicable systems and notify delegates as applicable; review decision to confirm accuracy and append to the system; document decisions in CAG and the care management system as applicable. For delegate cases, notify the applicable delegate of the decision via email. If decision is overturned, the Dispute Specialist will reach out to claims to facilitate the effectuation of the decision. For Grievances and Appeals : Perform administrative functions to close out Grievance and Appeal files; rout claims for adjustment; ensure validating adjustment was made correctly in accordance with the appeal decision; follow up with other business areas to ensure resolution actions were completed & document actions taken in CAG system. Ensure timeframes are met and files are completed per G&A operational policies and procedures. Monitor daily and weekly pending reports and CAG work list to ensure timely submission of files and resolution of final appeal and grievance actions. Classify / code CAG inquiries appropriately, entering all actions taken in investigation for auditing & reporting purposes. Make follow-up calls to provider or reach out to the dispute agent via email for any additional information. Liaison with Claims to ensure determinations are effectuated within stringent timeframes. Regular attendance is an essential function of the job. Perform other duties as assigned or required. Associates degree 1 - 2+ years' relevant, professional work experience Additional experience / specialized training may be considered in lieu of educational requirements Ability to work under pressure and deliver accurate and timely results Excellent communications skills (verbal, written, interpersonal) Working knowledge of Health Insurance processes Proficient with MS Office (Word, Excel, Powerpoint, Teams, Outlook, etc.) Excellent organizational, problem solving and analytical skills
Summary of Position
- Process disputes submitted by contracted and non-contracted providers. Types of correspondence handled by the individual will include, but is not limited to; correspondence, HQSI / ESMSEF appeals and Cotiviti disputes.
- Provide technical and administrative support to Grievance and Appeals dept. to ensure that departmental goals are met.
- Perform administrative tasks related to the resolution and closures of grievances and appeals.
Principal Accountabilities
Intake and preparation of Dispute Files for External Review :
Resolution of Disputes and Closure of Grievance and Appeals :
File Compliance
Qualifications
Additional Information
Requisition ID : 1000002759
Hiring Range : $39,960-$70,200
Create a job alert for this search
Dispute Specialist • New York, NY, United States
Related jobs
Grievance And Appeals Coordinators.Immediate need for a talented Grievance and Appeals Coordinators.This is a 06+months contract opportunity with long-term potential and is located in Portland Oreg...Show moreLast updated: 3 days ago
This individual would be responsible for reviewing, processing, investigating, evaluating, negotiating and the settling of assigned property damage or bodily injury claims with the authority level ...Show moreLast updated: 30+ days ago
Claim Specialist; Part time or Full time with flexible hours.Contractor, Home Inspector, Realtor, mortgage broker, real estate licensee, appraiser, contractor or related field? Learn to put your sk...Show moreLast updated: 8 hours ago
This AVP, Claim – Coverage & Complex individual contributor role requires a high degree of specialized and technical competence managing high exposure Financial Lines (D&O, E&O, EPL, Fidelity, & Tr...Show moreLast updated: 30+ days ago
AEGIS") has an immediate opening for a.Litigation Counsel or Senior Litigation Counsel.Professional Liability claims at the excess level.
Candidate will effectively manage assigned claims and p...Show moreLast updated: 30+ days ago
New Jersey and an official partner of the New York Giants, is seeking an experienced Workers’ Compensation Legal Assistant fluent in both.
Spanish and English to join our Freehold, NJ office.The ide...Show moreLast updated: 29 days ago
Grievance / Appeals Representative I.Virtual : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and a...Show moreLast updated: 1 hour ago
Bell Law Group is seeking an attorney with 2-8 years of employment litigation experience to join our Employment Litigation team.
This is an excellent opportunity for an attorney who is looking to gr...Show moreLast updated: 6 days ago
Clinical Professional Opportunity.You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management / Health Services team.Centene is a diver...Show moreLast updated: 7 hours ago
Brown & Brown's Risk Solutions team, formerly known as Beecher Carlson, is looking for a Claims Advocate to join the Executive Liability Practice in New York, NY.
The Claims Advocate is responsi...Show moreLast updated: 3 days ago
Data entry into excel spreadsheet.Contact information collection and documentation.Ability to triage complex customer inquiries, understand the appropriate parties to resolve, and minimize the numb...Show moreLast updated: 3 days ago
Taking care of our customers, our communities and each other.By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the industry for over 17...Show moreLast updated: 7 days ago International Benefits Specialist.Skadden, Arps, Slate, Meagher & Flom LLP (Skadden) has forged a reputation as one of the most prestigious law firms in the world.
By relying on innovation, intellec...Show moreLast updated: 8 hours ago 
Auto Telephone Claims Adjuster.National General Insurance is currently hiring for an experienced Auto Telephone Claims Adjuster.
We are able to hire remotely out of the following west coast states : ...Show moreLast updated: 1 day ago
Recruitment Incentive : Applicants may be eligible for a $40,000 recruitment incentive in accordance with regulatory requirements.
Click apply for complete details on the recruitment incentive detail...Show moreLast updated: 30+ days ago
Immediate openings for Member Appeals Specialist.Must have prior appeals and grievances experience.Monday - Friday 8AM-5PM EST $23 / hr.
Member Appeals Specialist duties include : .Case management of th...Show moreLast updated: 2 days ago
Through our dedicated associates, Conduent delivers mission-critical services and solutions on behalf of Fortune 100 companies and over 500 governments - creating exceptional outcomes for our clien...Show moreLast updated: 11 days ago
New Jersey and an official partner of the New York Giants, is seeking an experienced Workers’ Compensation Legal Assistant fluent in both.
Spanish and English to join our Freehold, NJ office.The ide...Show moreLast updated: 30+ days ago
- Promoted
Grievance and Appeals Coordinators
Pyramid ConsultingBronx, NY, USTemporary
- Promoted
Sr. Claims Specialist
W.R. BerkleyJersey City, NJ, USFull-time
- Promoted
- New!
Claims Specialist
Metro Public AdjustmentWayne, NJ, USFull-time +1
- Promoted
AVP, Claim - Coverage & Complex
ChubbJersey City, NJ, USFull-time
- Promoted
Litigation Counsel
AEGIS Insurance Services, Inc.East Rutherford, NJ, USFull-time
- Promoted
Workers' Compensation Legal Assistant
Garces, Grabler & LeBrocq CareersFreehold, New Jersey, USFull-time
- Promoted
- New!
Grievance / Appeals Representative I
Elevance HealthNew York, New York, United StatesFull-time
- Promoted
Litigation Associate (Labor & Employment)
Bell Law Group, PLLCSyosset, NY, USFull-time
- Promoted
- New!
Supervisor, Clinical Grievance and Appeals
NYC StaffingNew York, NY, USFull-time +1
- Promoted
Claims Advocate
Brown & BrownNew York, NY, USFull-time
- Promoted
Complaints Specialist
Indotronix Avani GroupFranklin Lakes, NJ, USFull-time
- Promoted
Litigation Specialist, Liability (Construction)
Travelers InsuranceNew York, NY, United StatesFull-time
- Promoted
- New!
International Benefits Specialist
NYC StaffingNew York, NY, USFull-time
- Promoted
Telephone Claims Adjuster
AllstateHempstead, NY, USFull-time
- Promoted
Special Agent, $40,000 Recruitment Incentive
The United States Secret ServiceWhite Plains, NY, USFull-time
- Promoted
Remote Appeals And Grievances Claims Coordinator
NY StaffingNew York, NY, USRemote
Full-time
- Promoted
Account Reconciliation Specialist
ConduentNewark, NJ, USFull-time
- Promoted
Workers' Compensation Legal Assistant
Garces, Grabler & LeBrocqFreehold, New Jersey, United States, 07728Full-time
Quick Apply