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Appeals Associate

Expired Job

Cigna Bedford , TX 76021

Posted 2 months ago

Job Summary:

Responsible for handling member and provider appeals/complaints involving medical necessity, retroactive authorizations, prescription drug coverage, and/or member eligibility. Responsible for tracking and reporting performance against HHSC guidelines. May complete intake, initialize the case for processing, and ensure cases are completed in a quality, organized, and timely fashion.

Essential Duties and Responsibilities:

  • Responsible for intake of appeals/complaint unit mail, sorting, and distributing within required timeframes.

  • Responsible for date stamping and properly identifying request type and region. Utilizes appropriate system to research required documentation for case work up.

  • Responsible for determining the appropriate type of response to a requested appeal or complaint.

  • Must determine deadline dates on all cases and ensure they are met or exceeded.

  • Contacts parties to obtain missing/outstanding information for processing and completion.

  • Prepares all correspondence to gather and investigate a case.

  • Obtains waivers of liability (WOL), authorization of representative (AOR), and medical records requests.

  • Refers cases to other departments to gather information to complete the investigation.

  • Maintains tracking and monitoring information on a database and software used in the department.

  • Provides tracking and trending reports to departmental leadership on the root causes of appeals and complaints and the high volume appellants.

  • Responds to Expedited and Provider Claim appeals.

  • Keeps current with all requirements of STAR PLUS plan appeals and complaints.

  • Provides training to peers as necessary in case handling.

  • Enters all job related activities in the applicable database

Knowledge, Skills, Abilities Required:

  • Comprehensive knowledge in STAR PLUS Appeals and Complaints and experience in managed care

  • Strong analytical skills, ability to formulate, write reports and professional correspondence

  • Knowledge of regulations and statutory language and interpretation

  • Understanding of the claims, membership and health services systems

  • Strong sense of customer service.

  • Excellent verbal and written communication skills.

  • Strong interpersonal skills including tact, diplomacy, and flexibility to work effectively with senior administration, staff and general public.

Qualifications:

  • High School Diploma or Equivalent

  • Knowledge and Proficiency with Microsoft Office

  • Strong data entry skills

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Appeals Associate

Expired Job

Cigna