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Claims Appeals Specialist

Company: SCAN Health Plan
Location: Long Beach
Posted on: November 21, 2022

Job Description:

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 action.
  • 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 disputed services.
  • 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 needed.
  • Actively support the achievement of SCAN's Vision and Goals.
  • 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 benefits.
  • 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 relationships.
  • 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 holiday
    • Excellent 401(k) Retirement Saving Plan with employer match
    • 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 - -https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html 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 60-1.35(c)

Keywords: SCAN Health Plan, Long Beach , Claims Appeals Specialist, Other , Long Beach, California

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