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Robert Half Denials Specialist in Los Angeles, California

Description

A health plan in the Mid-Wilshire area is in need of an Appeals Coordinator on a Contract to Hire Basis. The Appeals Coordinator MUST work 100% onsite in the office in Mid-Wilshire.

The Appeals Coordinator is responsible for the investigation, documentation and resolution of participant appeals in compliance with State/Federal law, rules, and guidelines. The Appeals Coordinator will perform research and utilize extensive claims knowledge to respond to inquiries and interpret plan/policy provisions.

This position interacts with the Health Plan staff, Plan participants, business managers, health care providers, medical insurance companies and related governmental agencies, and medical consultants. In addition to daily interaction with the Department Manager and Assistant Manager, this position also interacts with Executive Management whenever necessary.

ESSENTIAL FUNCTIONS

Work independently using discretion and independent judgment under the general supervision of the department manager and within broad parameters of policy established by management:

· Conduct research to advise management on medical claims issues and develop guidelines for use by the examiners or Participant Services Representatives when necessary.

· Research correspondence and appeals submitted by participants and providers.

· Manage documentation and correspondence for all appeals cases.

· Prepare and write appeals cases and present to the Benefit Committee.

· Coordinate reviews regarding the medical necessity of services with the Health Plan’s medical consultants. Write determination letters regarding the outcome of the reviews and send to the applicable participant/provider.

Requirements

  • Comprehensive knowledge of medical appeals

  • Prior experience in denials management is preferred

  • Knowledge of insurance regulations and policies, payment policies/guidelines and the ability to communicate and work with payers to get claims resolved and paid accurately desired

  • Minimum of at least 2-3 years of experience within the revenue cycle

  • Strong understanding of explanation of benefits (EOBs)

  • Medical claims experience preferred

Robert Half is the world’s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.

Robert Half puts you in the best position to succeed by advocating on your behalf and promoting you to employers. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity – even on the go. Download the Robert Half app (https://www.roberthalf.com/mobile) and get 1-tap apply, instant notifications for AI-matched jobs, and more.

Questions? Call your local office at 1.888.490.3195. Robert Half will consider qualified applicants with criminal histories in a manner consistent with the requirements of the San Francisco Fair Chance Ordinance. All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to temporary professionals. Visit https://roberthalf.gobenefits.net/ for more information.

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