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Appeals Specialist
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Full-time
- We offer HMO, PPO, and Medicare Advantage plans, Administrative Services for self-funded organizations, and Accountable Care Organization (ACO) administration and consulting.
- Under the direction of the Manager of Operations, the Appeals Specialist is responsible for ensuring the appropriate review, research, processing and responding to written member and provider complaints, appeals, and grievances.
- This position is required to apply analytical and critical thinking when reviewing contract language, benefits and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of Insurance in accordance with state and federal regulations, company policies and NCQA/HEDIS standards.
- Communicate accurate written responses to members conveying the Appeals Committees decisions within established timelines set by state and federal regulations, company policies, and NCQA standards to avoid punitive fines.
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