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

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 basisReview submitted appeals daily for validation of the appealIdentify appropriate claim problem within the appealPrepare 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 meetingsAttend and participate in Appeals Committee meetings as neededMaintain spreadsheet of all appeals reviewed with the outcomes resulting from the Appeals Committee MeetingsDocument within Facets the detailed information as to the outcome of the claim appealIdentify System changes, log the ticket and track the resolutionComplete claim appeal through claim adjustments or letters of denialsReview claim appeals for possible fraud and abuse and report to SIUResearch and release claim appeals with other health insurance, notifying the COB unit when there is other insuranceProcess 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 appealsResolve assigned appeals within regulatory timeframes, achieve departmental quality expectations, and meet daily production requirementsIdentify and log any related issuesPerform UAT testing when necessaryPerform any other job related instructions, as requestedEducation and Experience:High school diploma or equivalent is requiredAssociates Degree or equivalent years of relevant work experience preferredMinimum of two (2) years of healthcare customer service, claims, compliance or related experience is requiredCompetencies, Knowledge and Skills:Technical writing skillsIntermediate level skills in Microsoft Word & Excel with Access skills a plusCommunication skills (written, oral and interpersonal)Multitasking abilityAble to work independently and within a team environmentFamiliarity of the Healthcare fieldKnowledge of MedicaidTime ManagementDecision-making and/or problem solving skillsProper grammar skillsPhone etiquette skillsLicensure and Certification:NoneWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeCompensation 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:HourlyCompetencies:- Fostering a Collaborative Workplace Culture- Cultivate Partnerships- Develop Self and Others- Drive Execution- Influence Others- Pursue Personal Excellence- Understand the BusinessTrueCare 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.#LI-SD1