Medical Dispute Appeals Assistant

Job Summary

The Medical Dispute Appeals Assistant process appeals efficiently and appropriately per Bureau Worker's Compensation (BWC) guidelines. They review all pertinent medical documents within the claim to determine the most appropriate way to process the appeal. Medical Dispute Appeals Assistant communicates with parties of the claim to keep informed of the process.

Principal Duties & Responsibilities:

• Reports to the Medical Dispute Team Leader
• Refers and complies with the medical dispute policies and procedures
• Participates in the training of other medical dispute staff, as needed
• Identifies and requests appropriate documents for peer reviewers/examiners
• Completes accurately and thoroughly appropriate worksheet, checklist and timeline
• Communicates with the Customer Service Specialist (CSS) to clarify International Classification of Diseases (ICD) codes / descriptions as needed
• Enters actions codes accurately into UniSource
• Utilizes UniSource, Portal, Medical repository, Core Suite and Official Disability Guidelines
• Appropriately processes appeals based on options from Managed Care Organization (MCO) Chapter 5 policy reference guide
• Communicates with parties of the claim as needed to process appeals
• Discusses claim findings with Case Manager, Utilization Management Nurse, Clinical Liaison and others to resolve or clarify a disputed issue
• Responds promptly to emails and phone calls
• Promotes the independence of other staff members
• Analyzes medical dispute workflow to recognize opportunities for improvement and system upgrades / changes
• Generate Drug Utilization Review letters and track through completion
• Other duties as assigned and required by the needs of the company

• Complies with all pertinent Managed Care Organization (MCO) / Bureau Worker's Compensation policies (BWC)

• Complies and adheres to the Medical Dispute Appeals Assistant processes
• Understands and upholds Sheakley's philosophy and demonstrates commitment to the Cores Values and Sheakley's vision.

Education and Experience:

• Knowledge and skills at a level normally acquired through the completion of a High School education or GED equivalent and/or experience
• No written disciplinary in the past 6 months (for current Sheakley employees)
• Ability to function independently 95% of the time

Requirements:

• Attention to detail, flexibility and strong ability to multi-task
• Team player
• Ability to adapt to change
• Critical thinking and analysis
• Ability to problem solve and communicate effectively and professionally with internal and external customers
• Ability to answer high call volume while maintaining accurate documentation
• Completes tasks thoroughly and in a timely manner

Physical & Mental Demands:

• Ability to sit for prolonged periods of time.
• Advanced Microsoft Office and computer skills.

Sheakley is a family owned, outsourced human resources specialty firm dedicated to recognizing and meeting the growing needs of employers. Serving employers since 1963, we've evolved beyond our industry leading workers' comp and unemployment claims management programs to become one of the most respected and trusted providers of comprehensive payroll, time and labor management, and HR solutions and services. We proudly represent more than 50,000 clients.

We offer employees a range of perks including but not limited to:

• Competitive Pay
• Health, dental, vision, and life insurance
• Contributions to your HSA. $1100 for Individual, $2200 for family
• Additional insurance options: Critical Illness, Long Term, Short Term Disability, Accidental Death and Dismemberment, Employee Assistance Program, Legal Shield
• 401(k) savings plan with match after 1 year
• Continuous professional training and development
• 8 Paid Holidays
• Paid Vacation and PTO available
• Employee focused culture with appreciation events all year

This job description is not intended to be all inclusive and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required.

Current Openings for Medical Dispute Appeals Assistant Jobs at DO NOT USE Sheakley Group, Inc DO NOT USE