Appeals Specialist II - J00909

Appeals Specialist II - J00909

Position Title: Appeals Specialist II

Location: Remote

Duration: 06+ Months

Estimated Start Date: Jan 5th

Pay Rate: $23.00/hr on W2

Daily Schedule: Training Mon-Fri 8AM-5PM - 4 weeks - after the 4 weeks classroom setting, the candidate will be in 1 on 1 training for another 4 weeks. NO TIME OFF 8 weeks- CAMERA ON

Monday - Friday - No Overtime - no weekends

8am-5pm EST

Top Skills

• Knowledge of Prior Authorizations / UM
• Knowledge of Claims Resolution & Disputes / Claims Reconsiderations
• Multi-tasking skills (multiple systems at once), literate, computer knowledge, typing skills / internet speed a MUST

Position Purpose:

• The Resolution Team focuses on streamlining the post-clinical process between Utilization Management and Claims. The goal is to ensure every completed clinical review results in clear and timely claims, either pay or deny. This initiative enhances workflow efficiency, reduces misrouted or stalled cases, and strengthens communication across teams to improve overall operational accuracy and compliance.

Education/Experience:

• Requires a High School diploma or GED.
• Requires 1 - 2 years of related experience.

Day to Day

• Knowledge of appeals, disputes and reconsiderations process preferred.
• Performs data entry to support the tracking, logging, and processing of appeals, disputes and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures
• Prepares correspondence for appeals, disputes and reconsiderations and maintains documentation files
• Reviews and investigates appeals, disputes and reconsiderations requests to determine applicable follow up
• Conducts research needed to evaluate, process, and respond to appeals, disputes and reconsiderations to ensure a timely decision
• Prepares case files including supporting documentation and determinations needed to review, process, and report the appeals, disputes and reconsiderations
• Gathers appeals, disputes and reconsiderations data to track and report on trends and final outcomes to team including conducting outreach for an update on statuses, determinations, and explanations
• The Appeal Specialist II will manage cases returned from clinicians to the Resolution queues in TruCare after clinical review completion.
• This role is responsible for reviewing the outcome in TruCare and documenting clear payment or denial instructions in CenPAS through a Pulse Note, based on the authorization or appeal status.
• The coordinator will also review cases routed with the reason "Corp UM In Clinical Review" to determine if a clinician failed to send the task or if the case remains pending clinical review.
• Daily responsibilities include collaborating with internal partners, ensuring accurate case routing, maintaining compliance with turnaround time standards, and supporting process improvement initiatives.
• Performs other duties as assigned
• Complies with all policies and standards

Benefits:

BCforward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.

About BCforward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCforward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at will regardless of the anticipated assignment duration

Interested candidates please send resume in Word format Please reference job code 247695 when responding to this ad.

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