Claims Appeals Specialist
Company: SCAN Health Plan
Location: Long Beach
Posted on: September 19, 2022
SCAN Group is a not-for-profit organization dedicated to
tackling the most pressing issues facing older adults in the United
States. SCAN Group is the sole corporate member of SCAN Health
Plan, one of the nation's leading not-for-profit Medicare Advantage
plans, serving more than 270,000 members in California, Arizona,
and Nevada. SCAN has been a mission-driven organization dedicated
to keeping seniors healthy and independent for more than 40 years
and is known throughout the healthcare industry and nationally as a
leading expert in senior healthcare. SCAN employees are a group of
talented, passionate professionals who are committed to supporting
older adults on their aging journey, while also innovating
healthcare for seniors everywhere. Employees are provided in-depth
training and access to state-of-the-art tools necessary to do their
jobs, as well as development and growth opportunities. SCAN takes
great pride in recognizing our team members as experts in their
fields and rewarding them for their efforts. If you are interested
in becoming part of an organization that is innovating senior
healthcare visit -www.thescangroup.org , -www.scanhealthplan.com ,
or follow us on LinkedIn, Facebook, and Twitter.The jobReview all
incoming provider disputes and inquiries to ensure accurate system
intake and categorization. Perform outreach to delegated entities
and providers as required. Research and respond to Enterprise Cases
that may include claim adjustments, accelerated dispute resolutions
and forwarding of requested documents.You Will
- Intake and review provider disputes into the provider disputes
system for the purpose of tracking and issuing a decision. Apply
specific criteria to identify the correct dispute category,
provider contract status and Division of Financial Responsibility
(DOFR) application. Submit cases as needed for referral of medical
records. Create and monitor Request for Information.
- Ensure that all provider dispute packets contain complete
information for accurate review as required under regulatory
guidelines of SCAN policies.
- Understand and apply correct categorization of dispute request
to ensure accurate reporting and audit universe pulls.
- Review dispute requests from providers regarding SCAN payments
or payments made by delegated entities and determine appropriate
- Understand Division of Financial Responsibility (DOFR) and
apply to claim.
- Correspond with delegated entities as needed to obtain record
of their payment and/or denial decisions.
- Ensure all requests for information are initiated and received
in a timely manner.
- Understand and apply SCAN contract provisions, SCAN Policies
and Procedures, and regulatory guidelines to disputed claims.
- Issue correspondence regarding decision outcomes. Decision
letters must contain correct response information related to
- Process or adjust claim as needed.
- Refer non-contracted appeals appropriately. Refer and escalate
claims related issues and questions appropriately.
- Contribute to team effort by accomplishing related results as
- Actively support the achievement of SCAN's Vision and
- Required: Associates Degree or A comparable combination of
education/experience and/or training will be considered equivalent
to the education listed above.
- 3+ years claims processing experience with Medicare
- 2+ years claims experience with Medicaid benefits.
- 3+ years' experience in managed healthcare environment related
to claims processing.
- Understanding of regulatory guidelines related to Provider
Appeals and Payment Dispute Resolution (PDR).
- Demonstrated analytical ability.
- Knowledge of comprehensive medical terminology.
- Ability to establish and maintain positive and effective work
- Strong interpersonal skills, including excellent written and
verbal communication skills.
- Strong organizational skills; Ability to multitask.
- Ability to appropriately maintain confidentiality.
- Strong analytical and critical thinking skills, requiredWhat's
in it for you?
- A competitive compensation and benefits program -
- An annual employee bonus program
- Robust Wellness Program
- Generous paid-time-off (PTO)
- Eleven paid holidays per year, plus 1 additional floating
- Excellent 401(k) Retirement Saving Plan with employer
- Robust employee recognition program
- A work-life balance
- An opportunity to become part of a team that makes a difference
to our members and our community every day!To ensure a healthy and
safe work environment, if you are selected for this position, your
job offer with SCAN Health will be contingent upon being fully
vaccinated and providing proof of your COVID-19 vaccine within 3
days after your start date. Generally, you are considered fully
vaccinated 14 days after receiving the last dose, as recommended by
the manufacturer, of a vaccine that has been authorized by the FDA
for use in the United States, including vaccinations that have been
approved pursuant to an Emergency Use Authorization. If fully
vaccinated outside of the United States, the vaccination must be
listed for emergency use by the World Health Organization (WHO). If
you cannot receive the vaccine because of a disability/medical
reason or sincerely-held religious belief, you may request an
accommodation to this requirement by contacting -COVID-19
Vaccination Policy . Learn more about the COVID-19 vaccination here
We're always looking for talented people to join our team!
Qualified applicants are encouraged to apply now!At SCAN we believe
that it is our business to improve the state of our world. Each of
us has a responsibility to drive Equality in our communities and
workplaces. We are committed to creating a workforce that reflects
our community through inclusive programs and initiatives such as
equal pay, employee resource groups, inclusive benefits, and more.
-SCAN is proud to be an Equal Employment Opportunity and
Affirmative Action workplace. Individuals seeking employment will
receive consideration for employment without regard to race, color,
national origin, religion, age, sex (including pregnancy,
childbirth or related medical conditions), sexual orientation,
gender perception or identity, age, marital status, disability,
protected veteran status or any other status protected by law. A
background check is required. #LI-JR1Equal Opportunity
Employer/Protected Veterans/Individuals with DisabilitiesThe
contractor will not discharge or in any other manner discriminate
against employees or applicants because they have inquired about,
discussed, or disclosed their own pay or the pay of another
employee or applicant. However, employees who have access to the
compensation information of other employees or applicants as a part
of their essential job functions cannot disclose the pay of other
employees or applicants to individuals who do not otherwise have
access to compensation information, unless the disclosure is (a) in
response to a formal complaint or charge, (b) in furtherance of an
investigation, proceeding, hearing, or action, including an
investigation conducted by the employer, or (c) consistent with the
contractor's legal duty to furnish information. 41 CFR
Keywords: SCAN Health Plan, Long Beach , Claims Appeals Specialist, Other , Long Beach, California
Didn't find what you're looking for? Search again!