Job Description
Appeals & Grievances Resolution Specialist
Lead II – BPM
Who We Are
UST HealthProof is a dynamic company with a mission to lower the cost of care and deliver the future of healthcare. Our consumer-centric approach gives our health plan customers a modern infrastructure and reduced administrative costs, helping to drive better business results for our customers — and better outcomes for our communities.
We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States. **
You Are**
UST is searching for an individual who will support coordination of appeals and grievances intake, requesting medical records, and member/provider requests. Supports Appeals and Grievances team as required. **
The Opportunity**
- Conducts research and evaluation of incoming document received daily for multiple clients.
- Requesting medical records or other documentation as needed to complete case documentation.
- Classify each document to an appropriate case as a grievance or an appeal based on medical documentation.
- Protect the confidentiality of the member information and adhere to company policies regarding confidentiality.
- Maintain accurate and complete documentation of required information that meets quality standards.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. **
What You Need**
- Ability to work within urgent timeframes.
- Research, process, and resolve Participating provider appeals at all levels.
- Minimum of an associate degree required, preferably in health care related field
- Minimum of three-year experience in a health care related field
- Preferred setting is hospital, medical doctor’s office, or health insurance company.
- Appeals and grievances experience an advantage.
- Experience with medical terminology and concepts used in the healthcare delivery system, provider office, or the insurance industry is required.
- Computer literacy to include Microsoft Office products.
- Advanced technical skills for use of hardware and software with a high degree of accuracy.
- Excellent oral and written communication skills for representation of clear and concise results.
- Ability to manage significant workload, and to work efficiently under pressure, meeting established deadlines with minimal supervision.
- Strong time management skills.
- Must possess high degree of accuracy, efficiency, and dependability.
- Effective written and verbal communication and feedback
- Effective organizational skills with ability to be flexible and prioritize tasks.
- Skills: Healthcare, Medicare, Customer Support, Utilization Management, Appeals, grievance.
Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by local law, UST provides a reasonable range of compensation for roles that may be hired in California, Colorado, New York or Washington as set forth below. **
Role Location: Remote**
Compensation Range: $60,000-$90,000
Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits. **
What We Believe**
We’re proud to embrace the same values that have shaped UST HealthProof since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion, and to place people at the center of everything we do. **
Humility**
We will listen, learn, be empathetic and help selflessly in our interactions with everyone. **
Humanity**
Through business, we will better the lives of those less fortunate than ourselves. **
Integrity**
We honor our commitments and act with responsibility in all our relationships. **
Equal Employment Opportunity Statement**
UST HealthProof is an Equal Opportunity Employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.
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