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MEMBER SERVICES APPEALS SPECIALIST
DAYTONA BEACH FL 32117
Category: Health Care Industry
  • Your pay will be discussed at your interview

Job code: lhw-e0-90589709

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Florida Health Care Plans

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Summary

  Job posted:   Wed Jun 6, 2018
  Distance to work:   ? miles
       
  1 Views, 0 Applications  
 
MEMBER SERVICES APPEALS SPECIALIST
MEMBER SERVICES APPEALS SPECIALIST



Department:Member Services


Schedule:Full-time


Shift:1st shift


Hours:M- F; 8am - 5pm


Job Details:


+ Medical School Graduate


+ QUALIFICATIONS: Education, skills and experience: Successfully graduated medical school.Minimum of 3 years clinical experience, acceptable areas include Medical Surgical, Pediatrics, OB, ED, or ICU and/ or referral pre-certification, concurrent and post service experience required.Knowledge of Medicare criteria and nationally recognized criteria's preferred.Computer skills, typing skills: Proficiency with Microsoft Word/Outlook preferred.Must be able to type a minimum of thirty (20) wpm with ninety (90) % accuracy.Strong organizational and time management skills. Must be capable of multitasking.Strong telephone, oral communication and customer service skills required. Must be able to diffuse difficult situations.Must be able to work efficiently, independently and with others in a multidisciplinary team.Must be flexible in meeting the demands of all departmental operations.Bi-lingual a plus. POSITION SUMMARYMember services Grievance and Appeals Specialist will act as a member advocate while at the same time presenting and justifying the organizations actions in relationship to individual appeals. The position will analyze, research, and respond appropriately to member/provider appeals in a timely manner. The Specialist reviews members' benefits package for coverage, limitations, and exclusions. Gathers pertinent medical records and obtains guidelines, then matches the guideline to the medical records to determine if appropriate Clinical indications are met. The Specialist will contact social and regulatory agencies outside of FHCP and/or divisions within the organization in effort to address the member concerns. The position prepares the case for the Utilization Management Physician (UMP) review. Assists the UMP with case review, and applies the appropriate denial language post UMP review on denials of service.The position will accurately document research and outcomes in the Correspondence Unit Tracking system (CUT).


+ EOE/M/F/Vet/Disabled





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