grievance and appeals specialist

Alignment Healthcare

<div><p>Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.</p><p></p>
This position is remote in Orange, CA.<br>
<br>
The Appeals &amp; Grievance Coordinator is responsible for the day-to-day functions of the tracking and trending of all grievances, appeals, and complaints received within the Member Services Department. Acts as the primary investigator and contact person for member and provider grievances and appeals.<p></p><p><b>
GENERAL DUTIES/RESPONSIBILITIES :</b><br>
1. Acknowledges the receipt of all grievance/appeals, and CTM (Complaint Tracking Module).<br>
2. Gathers pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determines the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifies the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.<br>
3. Composes written correspondence to members in accordance to plan policy and CMS Guidelines.<br>
4. Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.<br>
5. Thoroughly documents all action taken on behalf of the member or provider to resolve the grievance/appeal.<br>
6. Ensures that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy.<br>
7. Prepares case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate.<br>
8. Prepares clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).<br>
9. Maintains accurate and timely documentation, including complete files of all grievances/appeals. Prepares monthly and quarterly reports as requested.<br>
10. Identifies training opportunities and potential system and process improvements relating to grievance/appeal data.<br>
11. Participates in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews.<br>
12. Other duties as assigned.</p><p></p><p><b>
Job Requirements:</b></p><p><b>
Experience:</b></p><ul><li>Required: Two years&rsquo; experience in data entry and general office background.</li></ul><p>
Three years of customer service experience. Minimum 1 year Member Services or similar experience.</p><ul><li>Preferred: 2 years healthcare or insurance experience in a senior setting.</li></ul><p><b>
Education:</b></p><ul><li>Required: High School Diploma or GED.</li><li>Preferred: Associate degree (A.A.) degree.</li></ul><p><b>
Training:</b></p><ul><li>Required:</li><li>Preferred:</li></ul><p><b>
Specialized Skills:</b></p><ul><li>Required:</li></ul><ul><li>
Knowledge of MediCal and Medicare Managed Care Plans.</li><li>
Ability to Keyboard/Type 40+ words per minute and use the 10-key by touch.</li><li>
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.</li><li>
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;</li><li>
Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.</li><li>
Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10&rsquo;s and 100&rsquo;s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.</li><li>
Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>Preferred: Bi-lingual (English/Spanish)</li></ul><p><b>
Licensure:</b></p><ul><li>Required: None</li></ul><p></p><p>
Work Environment:
</p><p>The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p><p>
The noise level in the work environment is usually moderate.</p><p>
Essential Physical Functions:</p><p>
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p><p></p><p>
1 While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.</p><p>
2 The employee is frequently required to walk; stand; reach with hands and arms.</p><p>
3 The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.</p><p>
4 The employee must occasionally lift and/or move up to 20 pounds.</p><p>
5 Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.</p>
Pay Range: $44,790.00 - $67,185.00<p>
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
</p><p></p><p>Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.</p><p></p><ul><li><i>DISCLAIMER: Please</i><i> beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal </i><i>information. Please</i><i> be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at </i><i>https://reportfraud.ftc.gov/#/</i><i>. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health&rsquo;s talent acquisition team, please email </i><i>careers@ahcusa.com</i><i>.</i></li></ul></div>

Appeals & Grievances Coordinator - Remote - Orange, CA

PacificSource Health Plans

<div><h1 class="jobSectionHeader"><b>Looking for a way to make an impact and help people?</b></h1><p></p><p><i>
Join PacificSource and help our members access quality, affordable care!</i></p><p></p><p><b>
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age.</b> PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person&rsquo;s talents and strengths.</p><p></p>
Provide clerical assistance to Appeals and Grievance team in entry and maintenance of case records. Provide high quality customer service to internal and external customers regarding appeals and grievance inquiries. Support member and ensure customer satisfaction.<p></p><p><b>
Essential Responsibilities:</b></p><ul><li>
Process intake of appeals and grievances into the departments tracking database.</li><li>
Monitor incoming documents via fax, web, email, USPS and route to appropriate entity in a timely manner and in accordance with department processes</li><li>
Maintain office supply inventory for the department.</li><li>
Communicate complex information related to A&amp;G rules and regulations, verbally and in writing, to internal and external customers.</li><li>
Effectively capture and transcribe meeting minutes.</li><li>
Work collaboratively in an objective, professional, diplomatic manner with all internal and external customers.</li></ul><p></p><p><b>
Supporting Responsibilities:</b></p><ul><li>
Provide clerical backup for other A&amp;G staff as needed.</li><li>
Meet department and company performance and attendance expectations.</li><li>
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.</li><li>
Perform other duties as assigned.</li></ul><p></p><p><b>
Work Experience:</b></p><p>
Minimum one year customer service, and/or claims processing, health insurance industry process experience required. Data entry experience preferred.</p><p></p><p><b>
Education, Certificates, Licenses:</b></p><p>
High School Diploma or equivalent required.</p><p></p><p><b>
Knowledge:</b></p><p>
Requires strong research, analytical and data entry skills. Experience using Facets, OnBase, and other software packages used by PacificSource is strongly preferred. Must have basic math skills, the ability to work under strict deadlines, and excellent organizational skills.</p><p></p><p><b>
Competencies:</b></p><p>
Adaptability</p><p>
Building Customer Loyalty</p><p>
Building Strategic Work Relationships</p><p>
Building Trust</p><p>
Continuous Improvement</p><p>
Work Standards</p><p>
Contributing to Team Success</p><p>
Planning and Organizing</p><p></p><p><b>
Environment:
</b></p><p>Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.</p><p></p><p><b>
Skills:</b></p>
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork<p></p><p><b>
Compensation Disclaimer</b></p><p>
The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.
</p><p><b>Base Range:
</b></p>$32,311.65 - $51,698.64<p></p><h1 class="jobSectionHeader"><b>
Our Values</b></h1><p>
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:</p><ul><li><p>
We are committed to doing the right thing.</p></li><li><p>
We are one team working toward a common goal.</p></li><li><p>
We are each responsible for customer service.</p></li><li><p>
We practice open communication at all levels of the company to foster individual, team and company growth.</p></li><li><p>
We actively participate in efforts to improve our many communities-internally and externally.</p></li><li><p>
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.</p></li><li><p>
We encourage creativity, innovation, and the pursuit of excellence.</p></li></ul><p></p><p><b>
Physical Requirements:</b> Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.</p><p></p><p><b>
Disclaimer:</b> This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.</p></div>

Appeals and Grievance Support (Monday-Friday)

Lakeland Regional Health

<p></p><div><div><div><div><div>Position Details<br>
</div></div><br>
<div><div><p>Lakeland Regional Health is a leading medical center located in Central Florida. With a legacy spanning over a century, we have been dedicated to serving our community with excellence in healthcare. As the only Provisional Level 1 Trauma center for Polk, Highlands, and Hardee counties, and the second busiest Emergency Department in the US, we are committed to providing high-quality care to our diverse patient population. Our facility is licensed for 910 beds and handles over 200,000 emergency room visits annually, along with 49,000 inpatient admissions, 21,000 surgical cases, 4,000 births, and 101,000 outpatient visits.
</p><p><b>Active - Benefit Eligible and Accrues Time Off
</b></p><p></p><b>Work Hours per Biweekly Pay Period: </b>80.00
<br>
<b>Shift </b>: Monday - Friday
<br>
<b>Location </b>: 210 South Florida Avenue Lakeland, FL - Remote after training
<br>
<b>Pay Rate </b>: Min $17.84 Mid $20.53
</div></div><br>
<div><div>Position Summary<br>
</div></div><br>
<div><div><p>Demonstrates commitment to the promises, vision, core purpose/mission and goals of LRMC, modeling the values and culture. Works under the supervision of the PFS Supervisor. The AR Follow and Denials Specialist is responsible for collecting payments for outstanding hospital claims, managing accounts, researching denials, submitting corrected claim requests, submitting appeals, and ensuring payments received are reconciled correctly with emphasis place on HIPAA compliance and in accordance with departmental goals, SOP&rsquo;s, and contract terms. Responsible for adhering to all Federal regulations and maintaining current knowledge of all Insurance guidelines. Escalates payer denials trends or claims issues to the PFS Leadership Team to address with the payer. Identifies trends, system issues, and potential process improvements to avoid future delays and denials.<br>
<br>
</p></div></div><br>
<p></p><div><div>Position Responsibilities<br>
</div></div><br>
<div><div><p><b>People At The Heart Of All We Do
</b></p><p></p><ul><li>Fosters an inclusive and engaged environment through teamwork and collaboration.
</li><li>Ensures patients and families have the best possible experiences across the continuum of care.
</li><li>Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created.
</li><li><b>Safety And Performance Improvement
</b><ul><li>Behaves in a mindful manner focused on self, patient, visitor, and team safety.
</li><li>Demonstrates accountability and commitment to quality work.
</li><li>Participates actively in process improvement and adoption of standard work.
</li><li><b>Stewardship
</b></li><li>Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities.
</li><li>Knows and adheres to organizational and department policies and procedures.
</li><li><b>Standard Work: AR Follow Up Denials Specialist
</b></li><li>Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives
</li><li>Responsible for all aspects of follow up and collections on accounts. This includes making outbound calls to payers and accessing payer websites.
</li><li>Collect payments for outstanding claims and ensure payments received are reconciled correctly.
</li><li>Confirm the claim expected reimbursement information to ensure claims are paid correctly. Follows department&rsquo;s process for follow up on underpayments/overpayments.
</li><li>Research and prepare responses for payor requests for additional information or documentation.
</li><li>Submits corrected claim rebill requests to the PFS Billing team when necessary to send to the insurance payer with correct information and ensures payment is received and claims are paid per contract
</li><li>Research denials and works with other departments such as Coding, Billing, CDM, UM, ect. to resolve denial.
</li><li>Submits the insurance reconsideration/appeals with supporting documentation in a timely manner and follow up with insurance to ensure receipt and processing. Follows insurance payer claims and appeals timely filing guidelines.
</li><li>Communicate clearly and professionally, in both written and verbal manners with internal personnel, payors, providers, patients, and other authorized representatives in regards to outstanding balances.
</li><li>Responsible for adequately working correspondence timely and efficiently (including EOBs, RA&rsquo;s, denial letters).
</li><li>Maintain knowledge of current government and carrier regulations, policies, manuals relevant to the industry.
</li><li>Identify and report trends in carrier payments and denials, which includes documentation of actions taken to resolve issues. Follows internal escalation process when necessary.
</li><li>Identify complex and aged claims issues and follows internal escalation process appropriately.
</li><li>Maintain patient confidentiality and privacy; adheres to HIPAA standards.
</li><li>Organizes job functions and work assignments to be able to effectively complete assignments within established time frames.
</li><li>Must meet department Productivity Guidelines. Works with all areas of the department to assure maximum productivity. Utilizes the PFS Productivity tracker.
</li><li>Demonstrates knowledge of all equipment and systems/technology necessary to complete duties and responsibilities.
</li><li>Other duties, responsibilities, and activities may change or be assigned at any time with or without notice.
</li></ul></li></ul></div></div><br>
<div><div>Competencies &amp; Skills<br>
</div></div><br>
<div><div><p>Essential:<br>
<br>
</p><ul><li>Four years general Patient Accounting experience including understanding of Managed Care contracts and claims analysis. Understanding of Medicaid, Medicaid Manage Care, Medicare, Medicare Advantage plans, Commercial, Liability, and Workers' Compensation payers and their guidelines. Knowledge of healthcare rules and regulations.
</li><li>An overall understanding of the appeals processes through completion.
</li><li>Ability to read/interpret EOB&rsquo;s
</li><li>Working knowledge of Word, Excel or other Microsoft applications. Good analytical skills for problem solving, typing of 40 WPM and data entry.
</li><li>Knowledge of Accounting Principles; analytical mathematical skills, professional customer service communication skills.
</li><li>Demonstrates accuracy and thoroughness; Meets productivity standards; Completes work in timely manner.
</li><li>Consistently shows ability to recognize and deal with priorities. Adapts to changes in the work environment; Able to deal with frequent change, delays, or unexpected events.
</li><li>Knowledge of HIPAA guidelines.
</li><li>Demonstrates good judgment and reasoning when investigating and solving problems. Good critical thinking skills.
</li><li>Ability to prioritize and manage time effectively.
</li></ul>Nonessential:
<ul><li>Ability to prioritize and manage time effectively.
</li></ul></div></div><br>
<div><div>Qualifications &amp; Experience<br>
</div></div><br>
<div><div><p>Essential:
</p><ul><li>High School or Equivalent
</li></ul>Nonessential:
<ul><li>Associate Degree
 </li></ul>Nonessential:
<p></p><ul><li>Business or Healthcare Administration
 </li></ul>Other information:
<p></p><div>Experience Essential:
<br>
<ul><li>Two years general patient accounting experience. Experience working with and general understanding of Medicaid, Medicaid Manage Care, Medicare, Medicare Advantage plans, Commercial, Liability, and Workers' Compensation payors.
</li></ul><br>
Experience Preferred:
<br>
<ul><li>Four years general patient accounting experience. Experience working with and general understanding of Medicaid, Medicaid Manage Care, Medicare, Medicare Advantage plans, Commercial, Liability, and Workers' Compensation payors.
</li></ul><br>
Certifications Preferred:
<br>
<ul><li>AAHAM or HFMA certification</li></ul></div></div></div></div></div></div><p></p>

AR Follow Up Denials Specialist - Denial & Appeals Mgmt

Pantherx Specialty Llc

<p></p><div><p><b>7,000 Diseases - 500 Treatments - 1 Rare Pharmacy</b></p><p><i>
PANTHERx is the nation&rsquo;s largest rare disease pharmacy, and we put the patient experience at the top of everything that we do.</i></p><p><i>
If you are looking for a career in the healthcare field that embraces authentic dedication to patient care, you don&rsquo;t need to look beyond PANTHERx. In every line of service, in every position and area of expertise, PANTHERx associates are driven to provide the highest quality outcomes for our patients.
</i></p><p><i>We are seeking team members who:</i></p><p><i>
Are inspired and compassionate problem solvers;</i></p><p><i>
Produce high quality work;</i></p><p><i>
Thrive in the excitement of the ever-challenging environment of modern medicine; and</i></p><p><i>
Are committed to achieving superior health outcomes for people living with rare and devastating diseases.</i></p><p><i>
At PANTHERx, we know our employees are the driving force in what we do. We cultivate talent and encourage growth within PANTHERx so that our associates can continue to explore their interests and expand their careers. Guided by our mission to provide uncompromising quality every day, we continue our strategic growth to further reach those affected by rare diseases.</i></p><p><b>
Join the PANTHERx team, and define your own RxARE future in healthcare!</b></p><p><b>
Location:</b> Pittsburgh, PA; Hybrid</p><p><b><br>
Classification:</b> Non-Exempt</p><p><b>
Status:</b> Full Time</p><p><b>
Reports to:</b> Manager, Clinical Programs</p><p><b>
Purpose:</b></p><p>
The Clinical Authorization and Appeals Specialist provides support and education to health care providers for prescribed treatment therapies. This role serves as a single point of contact for health care providers to coordinate alignment of documentation with prior authorization and appeals criteria. This role submits timely prior authorizations requests, appeals, initiatives to increase patient adherence, and closes collaboration with both internal and external stakeholders.</p><p><b>
Responsibilities:</b></p><ul><li>
Educates health care providers regarding prior authorization and appeals criteria for prescribed therapies.</li><li>
Assesses clinical documentation provided and assist the health care provider with alignment to specific plan criteria.</li><li>
Creates initiatives to increase patient adherence and optimize patient care.</li><li>
Possess a broad and deep understanding of assigned disease states, products, and clinical programs.</li><li>
Closes collaboration with program team members as well as external stakeholders.</li><li>
Performs appropriate and accurate documentation of cases using call management software.</li><li>
Demonstrates appropriate judgment skills to be able to make independent clinical decisions.</li><li>
Fosters teamwork by trusting and supporting each other while encouraging collaboration at all levels of the organization. Embraces diversity and demonstrates the ability to work together.</li><li>
Provides superior customer service to internal and external clients, customers, and patients.</li><li>
Assumes accountability for own professional practice in achieving patient outcomes.</li><li>
Completes all other duties as assigned.</li></ul><p><b>
Required Qualifications:</b></p><ul><li>
Associate degree or bachelor&rsquo;s degree from an accredited nursing school as a Registered Nurse (RN).</li><li>
Must have demonstrated competence in community health or patient care setting, providing direct patient care with patients for 1-3 years.</li><li>
Strong writing and grammar skills.</li><li>
Strong organizational skills and a thorough knowledge of computers (Microsoft Office and Windows) are required.</li><li>
Demonstrated ability to work independently and meet goals.</li></ul><p><b>
Preferred Qualifications:</b></p><ul><li>
1-3 years of specialty pharmacy experience</li></ul><p><b>
Work Environment:</b></p><p>
PANTHERx Rare Pharmacy offers flexibility only to eligible employees to work hybrid or remotely without compromising work performance, productivity, or team collaboration. This role routinely uses standard office equipment such as computers and phones.</p><p><b>
Physical</b> <b>Demands:</b></p><p>
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function of the job.</p><p><b>
Benefits:</b></p><p>
Hybrid, remote and flexible on-site work schedules are available, based on the position. PANTHERx Rare Pharmacy also affords an excellent benefit package, including but not limited to medical, dental, vision, health savings and flexible spending accounts, 401K with employer matching, employer-paid life insurance and short/long term disability coverage, and an Employee Assistance Program! Generous paid time off is also available to all full-time employees, as well as limited paid time off for part-time employees. Of course we offer paid holidays too!</p><p><b>
Equal Opportunity:</b></p><p>
PANTHERx Rare Pharmacy is an equal opportunity employer, and does not discriminate in recruiting, hiring, promotions or any term or condition of employment based on race, age, religion, gender, ethnicity, sexual orientation, gender identity, disability, protected veteran's status, or any other characteristic protected by federal, state or local laws.</p></div><p></p>

Clinical Authorization and Appeals Specialist

Served With Honor LLC

<div><p><b>Location: </b>Remote - US</p><p></p><p><b>
Position Summary:
</b></p><p>The Client Service Support Specialist is responsible for delivering personalized, accurate, and compassionate assistance to clients, their family members, and their caregivers as they navigate complex issues related to support services. The Client Service Support Specialist&rsquo;s goal is to ensure our clients feel heard, valued, and supported, and they will accomplish that goal by responding to inquiries with a balance of efficiency and empathy, ensuring every interaction is meaningful and every concern is met with urgency and understanding.</p><p></p><p><b>
Essential Functions:
</b></p><p>Reasonable accommodations may be made to enable individuals with disabilities to
</p><p>perform the essential functions.
</p><ul><li>Serve as the first point of contact for clients seeking support services, appeals, grievance, social service needs, billing issues, and insurance coverage.
</li><li>Listen actively to client concerns, respond with empathy, and deliver accurate, timely solutions across communication channels (phone, chat, email).
</li><li>Support clients navigating complex issues including appeals and grievance submissions and status updates.
</li><li>Billing discrepancies and insurance coverage clarifications.
</li><li>Community-based SDOH-related referrals.
</li><li>Escalations and compliance-sensitive concerns.
</li><li>Provide warm handoffs to internal specialists or external partners when additional expertise or intervention is needed.
</li><li>Document all interactions clearly and accurately in the CRM system to ensure continuity of care and compliance with policies.
</li><li>Recognize urgent or high-risk issues and escalate appropriately using established protocols.
</li><li>Maintain up-to-date knowledge of service offerings and regulations.
</li><li>Collaborate cross-functionally with internal departments.
</li><li>Participate in quality improvement efforts, team meetings, and feedback sessions to ensure excellent client experience.</li></ul><p></p><p><b>
Knowledge, Skills, and Abilities:</b></p><ul><li>Bachelor&rsquo;s degree required</li><li>A minimum of 3 years of customer experience in a healthcare contact center setting</li><li>Experience in a virtual contact center with digital navigation preferred</li><li>Demonstrated commitment to serving diverse populations with empathy, humility, and respect for cultural differences</li><li>Exceptional verbal and written communication skills, able to simplify complex information with compassion and clarity</li><li>Familiarity with billing processes, insurance plans, appeals, and grievance resolution</li><li>Understanding of Social Determinants of Health (SDOH) and ability to guide clients toward
</li></ul><p>appropriate resources</p><ul><li>Ability to remain calm and professional under pressure, especially when handling escalations</li><li>Demonstrated problem-solving skills and resourcefulness in navigating client needs</li><li>Experience working with HIPAA-regulated data and maintaining client confidentiality</li><li>Comfortable using CRM systems, ticketing platforms and digital communication tools</li><li>Strong organizational skills with attention to detail and follow-through</li><li>Ability to learn new processes and adapt to changes</li><li>Team-oriented, adaptable, and energized by a mission-driven, fast-paced environment</li><li>Use initiative to identify problems and provide solutions</li><li>Exceptional problem-solving and time management skills</li></ul><p></p><p><b>
Served with Honor</b> is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, marital status, disability or any other basis prohibited by law.</p><div></div><p><br>
Compensation Range: $40K - $50K</p></div>

Client Service Support Specialist

L.A. Care Health Plan

<div></div><div><div><div><div><div><div><div><p>Authorization Technician II
</p></div></div></div></div><div><div><div><div><b>Job Category: </b>Clinical
</div></div></div></div><div><div><div><div><b>Department: </b>Utilization Management
</div></div></div></div><div><div><div><div><b>Location:
</b>Los Angeles, CA, US, 90017
</div></div></div></div><div><div><div><div><b>Position Type: </b>Full Time
</div></div></div></div><div><div><div><div><b>Requisition ID: </b>13058
</div></div></div></div><div><div><div><div><div><b>Salary Range:</b> $47,840.00 (Min.) - $57,062.00 (Mid.) - $68,474.00 (Max.)</div><br>
<div></div>
<div>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation&rsquo;s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br>
<br>
Mission: L.A. Care&rsquo;s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br>
</div><div><div><div><div>Job Summary</div>
</div><div><div>
The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.</div><br>
<div></div>
<div>The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports.</div><br>
<div></div>
<div>In addition, the position performs data entry and processing of referrals/authorizations in the system, authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned.</div>
</div></div><div><div><div>
Duties</div>
</div><div><div>Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services any file that is a duplicate to one already processed in the system; appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%)</div>
<div></div><div>Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%)</div>
<div></div><div>Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%)</div>
<div></div><div>Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%)</div>
<div>Perform other duties as assigned. (10%)</div>
</div></div><div><div><div>
Duties Continued</div>
</div></div><div></div><div><div><div>Education Required</div>
</div><div><div>High School Diploma/or High School Equivalency Certificate</div></div></div><div><div><div>
Education Preferred</div>
</div></div><div></div><div><div><div>Experience</div>
</div><div><div><b>
Required:</b></div>
<p>At least 6 months of health care experience.</p><br>
<p></p>
<p>Experience working in a cross functional work environment.</p><br>
<p></p>
<p><b>Preferred:</b></p>
<p>Experience in Medi-Cal managed care.</p><br>
<p></p>
<p>1 year of experience in UM/Prior Authorization.</p>
</div></div><div><div><div>
Skills</div>
</div><div><div><b>
Required:</b></div>
<p>Demonstrated proficiency in Medical Terminology required.</p><br>
<p></p>
<p>Strong verbal and written office communication skills.</p><br>
<p></p>
<p>Proficient with Microsoft Office Suite and Adobe PDF. and</p><br>
<p></p><p>Excellent organizational, interpersonal and time management skills.</p><br>
<p></p><p>Must be detail-oriented and an enthusiastic team player.</p><br>
<div></div>
<div><b>Preferred:</b></div>
<p>Knowledge of QNXT computer systems a plus.</p><br>
<p></p>
<p>Knowledge of the UM patient referral process.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s health plan eligibility.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s benefits coverage.</p><br>
<p></p><p>Knowledge of Health Plan regulations.</p><br>
<p></p>
<p>Knowledge of HMO/UM functions.</p><br>
<p></p>
<p>Knowledge of ICD-10/CPT coding.</p><br>
<p></p><p>Proficient utilizing electronic medical records and documentation programs.</p>
</div></div><div><div><div>
Licenses/Certifications Required</div>
</div></div><div></div><div><div><div>Licenses/Certifications Preferred</div>
</div><div><div>Medical Coding Certification</div></div></div><div><div><div>
Required Training</div>
</div></div><div></div><div><div><div>Physical Requirements</div>
</div><div><div>Light</div></div></div><div><div><div>
Additional Information</div>
</div><div><div><b>
Required:</b></div>
<div>Weekends and holidays hours may be required, as well as OT based on a business need.</div>
</div></div></div><div><b>
Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.</div><br>
<div></div>
<div><b>L.A. Care offers a wide range of benefits including</b></div>
<ul><li>Paid Time Off (PTO)</li>
<li>Tuition Reimbursement</li>
<li>Retirement Plans</li>
<li>Medical, Dental and Vision</li>
<li>Wellness Program</li>
<li>Volunteer Time Off (VTO)</li></ul><div><br>
</div></div></div></div></div><p><br>
<b>Nearest Major Market: </b>Los Angeles
<br>
<b>Job Segment: </b>EMR, Claims, Data Entry, Medical Coding, Healthcare, Insurance, Administrative</p></div></div></div><div></div>

Authorization Technician II

Jordan Young Institute

<div><p><b>Title: </b>AR Follow-up and Denial Specialist</p><p><b>
Location:</b> Onsite &ndash; Virginia Beach, VA (Hybrid)</p><p><b>
Who we are:</b></p><p>
Aligned Orthopedic Partners is a well-respected private orthopedic team comprised of highly trained, board-certified orthopedic surgeons devoted to delivering patients with the highest orthopedic care possible. Our commitment to finding the best solutions for individual needs sets us apart from the competition. We take pride in providing exceptional care while remaining friendly, courteous, and efficient.</p><p>
Aligned Orthopedic Partners is recruiting an experienced AR Follow-up and Denial Specialist. The ideal candidate is experienced with analyzing and resolving insurance claim denials, correcting errors, and securing accurate reimbursement from payers. This role requires strong analytical, coding, and communication skills, with a focus on denial prevention, timely appeals, and collaboration across the revenue cycle team.</p><p><b>
What you will do:</b></p><p><b>
Claims Review &amp; Correction</b></p><ul><li>
Review denied and unpaid claims to verify coding and billing accuracy.</li><li>
Correct errors and submit revised claims when necessary.</li><li>
Investigate claims with no payer response to confirm receipt and follow up.</li></ul><p><b>
Denial Management &amp; Appeals</b></p><ul><li>
Analyze denials and generate effective, well-researched written appeals.</li><li>
Appeal denials through coding review, contract interpretation, medical record review, and direct payer interaction.</li><li>
Maintain detailed knowledge of payer websites and appeal processes for commercial and government payers.</li><li>
Ensure appeals and reconsideration requests are completed accurately and on time.</li></ul><p><b>
Trend Analysis &amp; Communication</b></p><ul><li>
Identify recurring denial trends or payer policy changes affecting reimbursement.</li><li>
Communicate trends to management and recommend process improvements to prevent reoccurrence.</li><li>
Support and participate in process and quality improvement initiatives.</li></ul><p><b>
Collaboration &amp; Education</b></p><ul><li>
Confer with coders, billing staff, and revenue cycle managers on coding or claim issues.</li><li>
Provide education to team members on payer policies and denial prevention.</li><li>
Collaborate on special projects and assist management with additional tasks as assigned.</li></ul><p><b>
Account Reconciliation</b></p><ul><li>
Work assigned follow-up queues, including identification of missing payments, overpayments, and credits on accounts.</li><li>
Document all actions taken in the practice management system.</li></ul><p><b>
What you bring to the table:</b></p><p>
You are a detail-oriented and dependable professional with a strong grasp of accounts receivable and denial processes. You take ownership of your work, communicate clearly, and consistently meet deadlines in a fast-paced environment. You bring:</p><ul><li>
Minimum of 3 years&rsquo; experience in a medical billing department (orthopedic or surgical experience strongly preferred).</li><li>
In-depth knowledge of healthcare billing, claims processing, payer follow-up, and appeals.</li><li>
Proficiency with payer websites, Microsoft Outlook, Word, and Excel.</li><li>
Coding knowledge sufficient to process denied claims and support appeals.</li><li>
Strong reasoning, critical thinking, analytical, and mathematical skills.</li><li>
Ability to work independently with high productivity and attention to detail.</li><li>
CPC certification preferred but not required.</li><li>
High School Diploma or GED required.</li></ul><p><b>
Equal Opportunity Employer</b></p><p>
Aligned Orthopedic Partners is an equal opportunity employer. We promote diversity of thought, culture, and background. We celebrate what makes us different and committed to building a team that represents a variety of experiences. All employment is decided on the basis of qualifications, merit, and business need.</p></div>

AR Follow-up and Denial Specialist

Search 10000+ Grievance and appeals specialist jobs near you this May. New roles added regularly across leading industries. Apply today.