- Humana (Raleigh, NC)
- …a part of our caring community and help us put health first** The Appeals Representative 4 Investigates and resolves member and practitioner issues. manages ... determine if an a grievance, appeal or further request is warranted. The Appeals Representative 4 + Review documents + Building cases + Inventory Management +… more
- Humana (Raleigh, NC)
- …of our caring community and help us put health first** The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a ... with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties… more
- UNC Health Care (Smithfield, NC)
- …teamwork and reflects UNC Health Care's mission and philosophy. Responsibilities: 1. Appeals & Managed Care Escalations: Project Manage all 3rd party appeals ... including researching and determining if carrier denial of claim is valid and if not, abstracts information from medical records to support appeal of denial. Works in conjunction with appropriate resources (Coding, HIM or clinicians) to ensure that appeal is… more
- Intermountain Health (Raleigh, NC)
- …such as debits/credits, required + Experience with insurance claim appeals , required + Excellent computer skills (including Microsoft Office applications), ... required- Familiarity with electronic remittances, required **Physical Requirements** + Interact with others by effectively communicating, both orally and in writing + Operate computers and other office equipment requiring the ability to move fingers and hands… more
- Cardinal Health (Raleigh, NC)
- …the appropriate system. + Manages and resolves complex insurance claims, including appeals and denials, to ensure timely and accurate reimbursement. + Processes ... denials & rejections for re-submission (billing) in accordance with company policy, regulations, or third-party policy. + More challenging claim cases + Investigates and updates the system with all information received from secondary insurance companies. +… more
- CVS Health (Raleigh, NC)
- …new claim handoffs, nurse reviews, provider complaints, grievance and appeals via target system. + Assists providers with credentialing/re-credentialing and ... contracting questions and issues. + Assist in compiling claim data for audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. + Work hours will be… more
- CVS Health (High Point, NC)
- …and escalates issues as appropriate through the system for grievances and appeals . + Initiates out-reach/welcome calls to ensure constituents expectations are met or ... exceeded. + Identifies trends and any emerging customer service issues and works to develop solutions to address potential problems and/or plan features of interest as an approach to improve understanding of benefit plans and increase post-enrollment member… more
- UNC Health Care (Chapel Hill, NC)
- …for the accurate and timely submission of claims follow up, reconsideration and appeals , response to denials, and re-bills of insurance claims, and all aspects of ... insurance follow-up and collections including interfacing with internal and external departments to resolve discrepancies through charge corrections, payment corrections, write-offs, other methods. + Research medical records to gather information and… more
- Highmark Health (Raleigh, NC)
- …of benefit billing practices through paid clams review. + Participate as pharmacy representative in onsite member appeals and grievances sessions. + Serve as ... a resource for technical staff. + Other duties as assigned or requested. **QUALIFICATIONS:** **Minimum** + High school diploma or GED + Experience in pharmacy prescription claims processing/submission/payment. **Preferred** + Associate degree + Pharmacy… more
- Veterans Affairs, Veterans Health Administration (Fayetteville, NC)
- …requiring Administrative Investigation Boards. Serves as the Quality Management representative on hospital committees. Analyzes risk management data to identify ... to risk management issues.. Notifies, educates and guides providers on the appeals process. Completes NPDB report and enter information as required. Provide… more