Position Purpose:
Supports the documentation and processing of appeals, disputes and reconsiderations to ensure they are in accordance with state and National Committee for Quality Assurance (NCQA) requirements. Support the team to ensure appeals, disputes and reconsiderations are reviewed and processed timely.
Education/Experience:
Requires a High School diploma or GED.
Requires 1 – 2 years of related experience.
Knowledge of appeals, disputes and reconsiderations process preferred.
Performs data entry to support the tracking, logging, and processing of appeals, disputes and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures
Prepares correspondence for appeals, disputes and reconsiderations and maintains documentation files
Reviews and investigates appeals, disputes and reconsiderations requests to determine applicable follow up
Conducts research needed to evaluate, process, and respond to appeals, disputes and reconsiderations to ensure a timely decision
Prepares case files including supporting documentation and determinations needed to review, process, and report the appeals, disputes and reconsiderations
Gathers appeals, disputes and reconsiderations data to track and report on trends and final outcomes to team including conducting outreach for an update on statuses, determinations, and explanations
Performs other duties as assigned
Complies with all policies and standards
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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Position Purpose:
Supports the documentation and processing of appeals, disputes and reconsiderations to ensure they are in accordance with state and National Committee for Quality Assurance (NCQA) requirements. Support the team to ensure appeals, disputes and reconsiderations are reviewed and processed timely.
Education/Experience:
Requires a High School diploma or GED.
Requires 1 – 2 years of related experience.
Knowledge of appeals, disputes and reconsiderations process preferred.
Performs data entry to support the tracking, logging, and processing of appeals, disputes and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures
Prepares correspondence for appeals, disputes and reconsiderations and maintains documentation files
Reviews and investigates appeals, disputes and reconsiderations requests to determine applicable follow up
Conducts research needed to evaluate, process, and respond to appeals, disputes and reconsiderations to ensure a timely decision
Prepares case files including supporting documentation and determinations needed to review, process, and report the appeals, disputes and reconsiderations
Gathers appeals, disputes and reconsiderations data to track and report on trends and final outcomes to team including conducting outreach for an update on statuses, determinations, and explanations
Performs other duties as assigned
Complies with all policies and standards
Story Behind the Need
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
The purpose of this team is to build authorizations for provider reconsideration claims received through CenPas. Once the authorizations are created, they are routed to our clinical partners for review and determination. This is a fast-paced, multifaceted team that manages a high-volume inventory and plays a critical role in supporting timely claim reconsideration processing. Additional team members are needed to help manage the growing authorization build workload, maintain service levels, and support operational efficiency.
Typical Day in the Role
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
Auth Builders are responsible for reviewing provider reconsideration claims received through CenPas, validating claim information across multiple systems, and building the required authorizations for clinical review and determination. This fast-paced role requires team members to navigate multiple applications, research claim details, and accurately create authorizations while managing a high-volume workload. Performance expectations include completing a minimum of 24 authorization builds per day, averaging 3 claims per hour, while maintaining quality and accuracy standards. What makes this role unique is that it supports a centralized Corporate Utilization Management function responsible for 27 Marketplace states and 14 Medicaid states, requiring team members to manage varying state requirements, products, and processes across a broad geographic footprint.
Candidate Requirements
Education/Certification
Required: High School diploma or GED
Preferred: Associate’s / Bachelor’s
Licensure
Required: N/A
Preferred: N/A
Years of experience required: 1 – 2 years of related experience (Provider reconsideration, appeals work, utilization management, authorization building preferably in TruCare)
Disqualifiers: No Authorization Building experience
Additional qualities to look for: TruCare & Amisys experience
- Top 3 must-have hard skills stack-ranked by importance
1
Authorization Building
2
Utilization Management
3
Critical Thinking
Candidate Review & Selection
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
Projected Manager Candidate Review Date:
1-2 days post shortlisting
Type of Interviews:
Interview via Teams – camera on
Required Testing or Assessment (by Vendor):
Next Steps
- Do you have any upcoming PTO?
- Colleagues to cc/delegate
Myriam M. Guardiola-Gonzalez
