Process Medical and Pharmacy denials within established timeframes, in accordance to policies, procedures, and contractual requirements.
Document denial and reason in data management systems.
Create and mail required denial documentation with member-specific information to providers and members.
Maintain a complete file of all denied requests.
Provide information on denials as requested.
Review file for completeness of required documentation, including confirmation of receipt of denial notification, copies of written notification, correspondence with members and providers.
Be a resource to providers and Medicaid Business Segment staff regarding specific denials and/or denial process.
Conduct peer reviews of denial documentation prepared by department colleagues to confirm compliance with requirements.
Review denial documentation prepared by a Third-Party provider to confirm compliance with requirements.
Provide requested information during appeals process.
Assist other departments in creating denial documentation as requested.
Requirements
1 year of Medicare, Medicaid or Managed Care experience.
1 year of experience in a medical/dental office, call center, or pharmacy.
High School Diploma or GED.
Nice-to-haves
Completion of Medical Assistant or Pharmacy Technician program.
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