Grievance & Appeals Specialist II

Grievance & Appeals Specialist II

This position supports TRICARE Prime Demo by CareSource Military & Veterans, which aims to enhance healthcare access and prioritize the unique needs of the military community. We encourage military affiliated individuals, veterans, military spouses, and those with prior TRICARE experience to apply.

The Grievance & Appeals Specialist II reviews appeals submitted by current providers and all future providers contracted with CareSource.

Essential Functions :

• Prepare the appeals for clinical review and be responsible for recording and tracking on a regular basis
• Review submitted appeals daily for validation of the appeal
• Identify appropriate claim problem within the appeal
• Prepare all clinical edit appeals for review by computer research, print claim from Facets system, and print off all the code descriptions to assist the reviewer in decision making for committee meetings
• Attend and participate in Appeals Committee meetings as needed
• Maintain spreadsheet of all appeals reviewed with the outcomes resulting from the Appeals Committee Meetings
• Document within Facets the detailed information as to the outcome of the claim appeal
• Identify System changes, log the ticket and track the resolution
• Complete claim appeal through claim adjustments or letters of denials
• Review claim appeals for possible fraud and abuse and report to SIU
• Research and release claim appeals with other health insurance, notifying the COB unit when there is other insurance
• Process a variety of appeals, including but not limited to : dental appeals, low difficulty appeals, non-clinical appeals (i.e. tobacco surcharge, etc.), medically frail appeals, RCP appeals, member and provider appeals
• Resolve assigned appeals within regulatory timeframes, achieve departmental quality expectations, and meet daily production requirements
• Identify and log any related issues
• Perform UAT testing when necessary
• Perform any other job related instructions, as requested

Education and Experience :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

Compensation Range : $40,400.00 - $64,700.00

CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly / salary) : Hourly

Organization Level Competencies :

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.