Appeals Analyst

Pyramid Consulting, Inc; United States; Remote; USD 80,000 - 100,000; Full time

Job summary

An innovative leader in the health insurance industry is seeking a skilled Appeals Analyst for a remote, long-term contract opportunity. In this role, you will be responsible for analyzing and resolving confidential appeals and coding disputes while ensuring compliance with regulatory guidelines. This position offers a chance to work with a dynamic team and make a significant impact in a fast-paced environment. If you are passionate about healthcare and possess the necessary skills, this opportunity could be your next career move.

Benefits

Health Insurance (Medical, Dental, Vision)

401(k) Plan

Paid Sick Leave

Qualifications

• Must be CPC certified with 3 years of related experience.
• Bachelor's degree or 5 years of relevant experience in lieu of degree.

Responsibilities

• Analyze and resolve appeals and coding disputes.
• Document findings and ensure compliance with regulations.

Skills

CPC Certification

Health Insurance Experience

Appeals Handling

Analytical Skills

Communication Skills

Education

Bachelor's Degree

Advanced Degree

Tools

Care Radius

Job description

Pyramid Consulting, Inc provided pay range

This range is provided by Pyramid Consulting, Inc. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$26.00/hr - $28.00/hr

Immediate need for a talented Appeals Analyst. This is a 12+ months contract opportunity with long-term potential and is located in U.S(Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-70351

Pay Range: $26 - $28/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.
• Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers.
• Regularly and independently exercise judgement to make appropriate decisions based on client’s policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
• Prepare files and develops client’s position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants.
• Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines.
• Document extensive investigation, relative findings, and actions in all applicable systems
• Accountable for monitoring daily reports to ensure service timeliness and compliance is met.
• Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances.
• Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance – NCQA), ASO group performance guarantees and client’s policies and procedures (to include BCBSA requirements).

Key Requirements and Technology Experience:

• Key skills; MUST BE CPC (CERTIFIED PROFESSIONAL CODING) CERTIFIED.
• Care Radius experience.
• Experience in health insurance industry
• Experience in handling appeals and grievances from providers regarding claim denials.
• Bachelor’s degree or advanced degree where required.
• 3 years of related experience
• In lieu of degree, 5 years of related experience
• CPC required
• Able to work with a large team (about 29 others).
• Desk management and organizational skills.

Our client is a leading Health Insurance Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here.

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Contract

Job function

• Job function

  Information Technology

• Industries

  IT Services and IT Consulting

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