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Appeals Processing Senior Representative
Ref No.: 19-07952
Location: Bedford, Texas
Appeals Processing Senior Representative
Location: 2208 North Highway Bedford, TX 76021
Pay: $16.93-20.00/hr
Contract: 12/30/2019 - 3/31/2020
Schedule: Mon-Fri 8:00AM-5:00PM

The Investigator is responsible for the analysis, investigation and resolution of provider claim disputes.

Essential Duties and Responsibilities:
  • Conducts analysis, investigation and resolution of provider disputes
  • Review, analysis and triage of all cases received.
  • Responsible for determining the appropriate type of response to a requested dispute.
  • Must determine deadline dates on all cases and ensure they are met or exceeded.
  • Prepares all correspondence to gather and investigate a case.
  • Independently makes decisions about the resolution of their assigned cases.
  • Produces all documentation to support the decision.
  • Documents the decision in a resolution letter to the appellant.
  • Maintains tracking and monitoring information on a database and software used in the department.
  • Keeps current with all requirements the EVV disputes and processes.
  • Provides training to peers as necessary in case handling.
  • Enters all job related activities in the applicable database
  • Comprehensive knowledge of Medicaid/Medicare, including Appeals and Claims.
  • Strong analytical skills, ability to formulate, manage excel files, and professional correspondence
  • Knowledge of regulations and statutory language and interpretation
  • Understanding of the claims, membership and health services systems
  • Strong sense of customer service.
  • Excellent verbal and written communication skills.
  • Strong interpersonal skills including tact, diplomacy, and flexibility to work effectively with senior administration, staff and general public.
  • Knowledge and Proficiency with Microsoft Office
  • Strong data entry skills
  • High School Diploma
  • English Read Write Speak