Medical Data Entry Clerk- FULLY REMOTE

TekSystems is currently hiring for a FULLY REMOTE Medical Data Entry Specialist!

MUST HAVE: Must be on EST time zone to be considered, Must have any healthcare administrative, medical billing, claims, grievances, appeals experience, or something related!

Description

REMOTE

SHIFT: Mon - Friday, 9am - 5pm EST

POSITION OVERVIEW:

The client backlog of 10,000 appeals and grievances so these Data Entry Reps will be filtering through the appeals and take the following actions....

Summary of Position:

Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers in accordance

with NCQA, CMS, State and other regulations.

Process appeals and grievances to facilitate the accurate administration of benefits and clinical policy; ensure compliance of

the appeal and grievance process with all regulatory requirements and NCQA standards.

Work as an effective interface between internal and external customers

Maintain good member and provider relations

Principal Accountabilities:

Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider

appeals.

Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.

Provide written acknowledgment of member and provider correspondence.

Responsible for making verbal contact with the member or authorized representative during the research process to

further clarify, as needed, the member's complaint or appeal.

Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and

obtaining responses and information from internal and external entities.

Serve as liaison with EmblemHealth departments, delegated entities, medical groups and network physicians to

ensure timely resolution of cases.

Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as

required (such as the Legal Department) to clarify legal ramifications around complex appeals.

Follow-up with responsible departments and delegated entities to ensure compliance.

Accurately and completely prepare cases for medical and administrative review detailing the findings of their

investigation for consideration in the plan’s determination.

Monitor daily and weekly pending reports and personal worklists, ensuring internal & regulatory timeframes are met.

Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all

appeals reviewed through the IRE.

Identify areas of potential improvement and provide feedback and recommendations to management on issue

resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving

opportunities, best practices, and performance issues.

Prepare written responses to all member and provider correspondence that appropriately address each complainant’s

issues and are structurally accurate.

Ensure documentation requirements are met: create and document service requests to track and resolve issues;

Additional Skills & Qualifications

Relevant Work Experience, Knowledge, Skills, and Abilities

3+ years of related professional work experience.

Prior health industry and/or compliance work experience.

Additional years of experience/training may be considered in lieu of educational requirements.

Excellent verbal and written communications skills.

Experience in a managed care/compliance environment.

Ability to comprehend and produce grammatically accurate, error-free business correspondence.

Customer service experience.

Proficiency in MS Office applications (especially word processing, and database/spreadsheet).

Excellent product knowledge.

Excellent problem solving and analytical skills.

Ability to work under pressure and deliver complete, accurate, and timely results.

Excellent organization and time management skills.