Clinical Appeals Ops Lead: Determinations & Expedited

Jobtailor; Connecticut; On-site; USD 42,000 - 62,000; Full time

Job summary

Jobtailor in Connecticut seeks an Appeals Processor to handle daily Commercial Member Clinical Appeals (CMCA), draft determination letters, and intake expedited requests with accuracy.

You will collaborate with Medical Directors, Nurses, and Providers, triage faxes, update systems, and move cases through the Complaints and Appeals Tracking System (CATS) while upholding regulatory timelines.

Qualifications

• Familiar with Medical Terminology
• Strong written and verbal communication
• Ability to multi-task
• Proficient in basic computer skills including Microsoft Office Suite
• High School Diploma

Responsibilities

• Process daily appeals for Commercial Member Clinical Appeals (CMCA)
• Complete appeals determination letters
• Intake and launch expedited requests
• Provide verbal expedited notifications and determinations
• Update systems and complete reporting as necessary
• Support the panel hearing process
• Collaborate with clinical support staff, including Medical Directors, Nurses, and Providers
• Triage faxes
• Move cases through the Complaints and Appeals Tracking System (CATS)
• Handle work in compliance with turnaround times and regulatory standards

Skills

Medical Terminology

Written Communication

Verbal Communication

Multi-tasking

Collaboration

Education

High School Diploma

Tools

Microsoft Office Suite

Job description

Jobtailor in Connecticut seeks an Appeals Processor to handle daily Commercial Member Clinical Appeals (CMCA), draft determination letters, and intake expedited requests with accuracy.

You will collaborate with Medical Directors, Nurses, and Providers, triage faxes, update systems, and move cases through the Complaints and Appeals Tracking System (CATS) while upholding regulatory timelines.