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.”
===================
Story Behind the Need
Multiple Health Plans – Medicaid LOB only
• Transfer and evaluate cases from CenPAS and review provider disputes / reconsideration requests from providers/facilities
• Modify authorizations
• Respond to claims/UM
Describe the performance expectations/metrics for this individual and their team:
• Dependent upon assigned role
Tell me about what their first day looks like:
• Meet with leaders and start learning system/processes
What previous job titles or background work will in this role?
• Utilization Management
• Billing/coding (typically found in medical practices/facilities)
• Claim processing
Reason for request is to backfill a Beeline position that recently became available in June 2025.
Any future projected positions potentially coming up? NO If yes, note: unknown at this time
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?
Remote with virtual assistance. Teams/Camera/Huddles and 1:1 with Leadership. Candidate will review cases in CENPAS and claims in the AMISYS system to determine resolution on provider reconsiderations.
After full training, the performance metric is to complete 50 case reviews each day with a 95% or better overall monthly Quality average.
The ability to gain knowledge in multiple Health Plans.
Candidate Requirements
Required: High School Diploma/ GED
Preferred: N/A
Required: N/A
Preferred: N/A
Years of experience required: 2 years appeals, claims, authorizations
Must haves: Knowledge with reviewing claims and authorizations, familiar with TruCare, Amisys
Disqualifiers: poor attendance
Additional qualities to look for: fast learner, open to feedback, team player
- Top 3 must-have hard skills stack-ranked by importance
1
Data Entry/ Typing 40 wpm
2
Knowledgeable with Claims/Coding
3
Knowledgeable with Authorizations
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:
Teams- Cameras On
Required Testing or Assessment (by Vendor):
Typing test, basic computers skills test
Next Steps
- Do you have any upcoming PTO?
N/A
- Colleagues to cc/delegate
Myriam Guadiola-Gonzalez
Compliance Questions
- (Department of Defense) Will this role operate, support, or utilize DOD data, systems, and/or infrastructure, requiring a National Agency Check with Law and Credit Checks (NACLC)? (Vendors: If yes, NACLC check is required).
No
- Does this position require a Driver’s License to complete the necessary job functions for this role (E.g. Driving to member visits, hospital or provider facilities, sales)? (Vendors: If yes, MVR check is required).
No
