Medical Claims Specialist (CPC)

Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines. Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers. Regularly and independently exercise judgement to make appropriate decisions based on policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact. Prepare files and develops position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants. Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines. Document extensive investigation, relative findings, and actions in all applicable systems Accountable for monitoring daily reports to ensure service timeliness and compliance is met. Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances. Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance NCQA), ASO group performance guarantees and policies and procedures (to include requirements). Bachelor’s degree or advanced degree where required. 3 years of related experience In lieu of degree, 5 years of related experience For coding disputes area, certified professional coder must be obtained within 1 year of employment.Company DescriptionSelect Source International (SSI) is a distinguished staffing company with nearly 25 years of experience, renowned for delivering top-tier workforce solutions encompassing staffing, recruiting, and managed services. As a proud supplier, we bring a wealth of expertise and best-in-business differentiators to comprehensively support your diverse workforce needs.Based in Minneapolis, Minnesota, USA, SSI has established itself as a global leader, serving a broad clientele across industries with unwavering dedication and excellence. SSI is ISO 9001, 14001, and Soc2 Type2 certified, underscoring our commitment to quality and security. We have garnered numerous sustainability and supplier diversity awards, further validating our industry-leading capabilities

Salary : $25 - $28