Remote Inquiries, Appeals, and Dispute Analyst

Job Description:

Job Description

The Inquiries, Appeals, and Dispute Analyst role is responsible for the investigation of the referral/authorization episodes to determine approval or non-approval and respond accordingly to the Home Plans requests.

WHAT YOU'LL BE DOING

• Review and Finalize 095 and PDC reports of claims sent to the Home Plan needing review and status of approval and or payment/denial.
• Responsible for reviewing and responding to the email inquiries received from the Home Plans.
• Responsible for reviewing and working on the reconciliations of members out of pocket maximums received from the Home Plans.
• Responsible for reviewing and resolving claim inquiries from internal staff.
• Investigate and analyze the validity of claim appeals and disputes.
• Prepare and submit comprehensive responses to appeals and disputes, outlining findings and recommendations.
• Identify root causes of denials or disputes.
• Communicate resolutions to members, providers, or other stakeholders.
• Responsible for responding to Blue Cross appeals, grievances, and DOI appeals.
• Respond promptly and accurately to inquiries regarding claim status, coverage, and payment.
• Gather necessary information and documentation to address inquiries effectively.
• Escalate complex inquiries to appropriate personnel when necessary.

Qualifications

WHAT YOU'LL NEED TO HAVE

• Minimum 2-5 years’ claims processing experience.
• CPT and ICD coding knowledge.
• Ability to read and understand benefit plan descriptions.
• Ability to work independently and prioritize tasks to meet deadlines.
• A clear understanding of coding requirements ie: CPT and ICD codes and medical terminology.
• Intermediate to advanced understanding of Microsoft Office products ie: Excel, Word, Access, etc.
• Able to solve problems, exercise initiative, and make role level decisions.
• Thorough understanding of claims processing compliance requirements.
• Ability to meet deadlines and prioritize tasks and assign work daily to the staff.
• Ability to work independently with minimal supervision.
• Effective written and oral communication.
• Other duties as assigned.

WHAT WE'D LOVE FOR YOU TO HAVE

• Certified Professional Biller (CPB), Certified Professional Coder (CPC), or other similar certifications.
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.

Additional Information

The salary for this position is $53,000.00.

BENEFITS:

All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development.

• Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
• Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
• Support Your New Family: Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

COMPENSATION:

The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT 

Diversity, inclusion, and belonging are at the core of Guidehealth’s values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances.

OUR COMMITMENT TO PROTECTION OF PATIENT AND COMPANY DATA

This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealth’s custodianship as well as Guidehealth Intellectual Properties.

REMOTE WORK TECHNICAL REQUIREMENTS

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 50 mbps download, 10 mbps upload.