MANAGED CARE APPEALS REPRESENTATIVE

Aspire Health Partners - Orlando, FL

Full-time - Mid Level

Orlando, FL

1,001-5,000 employees

Ambulatory Health Care Services

About the position

The Managed Care Appeals Representative plays a crucial role in reviewing and resolving denied or disputed insurance claims related to behavioral health services. This position involves managing medication prior authorizations and ensuring timely administration of medications. The representative will work closely with various departments to address authorization issues and maintain high standards of ethical conduct while adhering to agency policies.

Responsibilities

• Review and analyze claim denials to perform the appropriate appeals necessary for reimbursement.
• Obtain necessary medical documentation needed for appeal submission.
• Submit written appeals to insurance carriers and follow up on the status of submitted appeals.
• Document and create reports of all appeal activity in appropriate systems and maintain organized records of all appeals.
• Collaborate with Utilization Review and Patient Accounts to resolve any authorization issues.
• Stay current with payor authorization requirements such as time frames.
• Provide excellent customer service to patients, healthcare providers, and insurance carriers.

Requirements

• A bachelor's degree in a relevant field such as Healthcare, Nursing, Performance, Law, Business, Management or Health.
• RN or LPN preferred with Behavioral Health experience.
• Ability to receive and maintain a Level II Background clearance.
• Acceptable Motor Vehicle Registration driver's license record in accordance with the underwriting guidelines set by Aspire insurance company.
• 3+ years of experience initiating appeals with Managed Care or Commercial Payors for reimbursement.
• Utilization and/or Case Management experience recommended.
• Proficient in data manipulation and spreadsheet development including pivot tables using Microsoft Excel and other Microsoft Office products.
• Strong communication skills, both verbal and written.
• Strong knowledge of medical terminology, coding systems (ICD-9, ICD-10), and managed care guidelines.

Nice-to-haves

• Ability to multitask, prioritize tasks and meet deadlines.
• Ability to learn and utilize the EHR system.
• Strong analytical/deductive, mathematical analysis and problem-solving skills.
• Ability to work independently and effectively under pressure to meet deadlines.
• Flexible and willing to perform other tasks as assigned.

Benefits

• Medical, Dental, Vision, Basic Life & Supplemental Insurance
• Flexible Spending & Health Savings Accounts
• Paid Time Off (PTO) (2.5 weeks your first year, up to 6 weeks at 14+ years)
• Paid Diversity & Floating Holidays (2)
• Paid Holidays (6)
• 403(b) 50% employer match up to 10% (3-year vesting cliff)
• Employee Discounts including Tickets, Retail, Hotel, Car Rental/Purchase
• Short-Term & Long-Term Disability Insurance
• HRSA Loan Forgiveness
• Employee Assistance Plan (EAP)
• Will preparation
• Funeral Planning
• Concierge Services & Travel Assistance