Mne Appeals Specialist - Oak Brook, United States - PBA

PBA

Verified Company

Oak Brook, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

Professional Benefit Administrators lead with one guiding principle, provide exceptional benefit administration for self-funded health plans. Brokers who choose to partner with PBA will benefit from an ally who values cost containment, flexibility, responsiveness, member advocacy, transparency, and results.

PBA collectively aligns through the organization's core values of:

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Work together and respect each other,
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Be dedicated to the customer,
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Be accountable and do what you say,
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Take initiative and be willing to learn and
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Generate positive energy.

Summary of Position:

The MNE/Appeals specialist is responsible for reviewing incoming documentation received in the Coordinated Care department while serving as a liaison between PBA and its Utilization and Care Management partners.

This position will have an in-depth knowledge of claims as well as strong written and verbal communication skills. This individual reports to the Quality Supervisor of the Coordinated Care department. Please see below for a more in-depth overview of daily responsibilities and skills required for this position.

Responsible for:

Review incoming medical records and determine if medical necessity has been submitted.
Review incoming appeals.
Determine if PBA can respond based on the plan document wording.
Send records to the appropriate UR vendor for review.
Document JV patient notes clearly for all PBA departments.
Document patient notes, update excel spreadsheet case.
Create and send out letters to provider and copy in employee of the review/appeal determination.
Send WORD document letter to mailroom to print and mail to employee.
Upload copies of letters to JV system.
Fax letters to providers.
Notify the assigned analyst of any claims to be reprocessed.
Ensure quality of workflow between PBA and UR/CM/DM partners.
Manage the appeals process to IRO level.
Other duties as assigned.

Minimum Job Requirements:

Knowledge of ERISA and nonERISA/ Grandfathered and non

- grandfathered plans.

2+ years prior knowledge/understanding of claims.
Excellent oral and written communication skills_
, _Friendly, compassionate manner
2+ years of prior work with CPT/ICD 10 codes.
Javelina claims system experience a plus.
PC, keyboard skills and use of Outlook, Word, Excel, with the ability to master additional information.
Must be able to maintain a positive work atmosphere by behaving and communicating in a manner so that you get along with peers, subordinates, customers, clients, and management.
Result oriented with a strong customer focus.
Good organizational skills.
Multitask and prioritize projects throughout the day.
Ability to work and interface with various levels of the organization.

Physical Demands

This is largely a sedentary role which requires the ability to sit for long periods of time.
To perform the physical requirements of the position, this person must be able to possess manual dexterity in their hands.

Essential Functions Statement

The person in this position will work in the office up to 4 times per month. The other days can be worked either in the office or remotely.

Professional Benefit Administrators are an equal opportunity employer. In accordance with anti-discrimination law, it is the purpose of this policy to effectuate these principles and mandates. Professional Benefit Administrators affords equal employment opportunities to all employees and applicants and specifically prohibits any and all discrimination and harassment based on race, race-related traits, color, religion, national origin, ethnicity, ancestry, military status, sex, pregnancy, sexual orientation, gender identity, disability (mental or physical), age, marital status, citizenship status, unfavorable military discharge, genetic information, order of protection status, and any other protected status under federal, state, and local law. Professional Benefit Administrators conform to the spirit as well as to the letter of all applicable laws and regulations.

Pay:
$ $28.00 per hour

Benefits: