LR06 - Paralegal/Legal Assistant - Mid-Level
Kelly Services eAccounts, Bedford TX
Temporary A&C Investigator needed in Bedford, TX
Length of Contract: 6 months
Pay: $13.50/hr - $16.50/hr
The Investigator is responsible for the analysis, investigation and resolution of member A&C, contracted and non-contracted provider appeals, Fair Hearings, as well as, for the timely and accurate resolution of call assigned cases and for the composition of the resolution letters for all types of cases.
Essential Duties and Responsibilities:
- Conducts analysis, investigation and resolution of member appeals and complaints
- Functions as the resource on contracted and non-contracted provider appeals.
- Review, analysis and triage of all cases received via Call Tracker or in writing.
- Prepares cases for second level appeals, QOC, fair hearing, or court preparation.
- Responsible for determining the appropriate type of response to a requested appeal or complaint.
- Must determine deadline dates on all cases and ensure they are met or exceeded.
- Prepares all correspondence to gather and investigate a case.
- Prepares a history of the investigation for each case.
- Obtains clinical input as needed to resolve cases requiring medical input.
- Refers cases to other departments to gather information to complete the investigation.
- Independently makes decisions about the resolution of their assigned cases.
- Produces all documentation to support the decision.
- Documents the decision in a resolution letter to the appellant or grievant.
- Ensures that overturns that require claims payment are processed with proof of payment placed in the file.
- Maintains tracking and monitoring information on a database and software used in the department.
- Provides tracking and trending reports to departmental leadership on the root causes of appeals and complaints and the high volume appellants.
- Prepares cases for external review.
- Responds to Expedited and Provider Claim appeals.
- Keeps current with all requirements of STAR+PLUS plan appeals and complaints.
- Provides training to peers as necessary in case handling.
Knowledge, Skills, Abilities Required:
- Comprehensive knowledge in STAR+PLUS Appeals and Complaints and experience in managed care
- Strong analytical skills, ability to formulate, write reports and professional correspondence
- Knowledge of regulations and statutory language and interpretation
- Understanding of the claims, membership and health services systems
- Strong sense of customer service.
- Exceptional written communication skills with a focus on brevity and clarity. (Grammar, punctuation, spelling.)
- Strong interpersonal skills including tact, diplomacy, and flexibility to work effectively with senior administration, staff and general public.
- BA/BS degree or comparable experience in Health Care Management or related field
- Knowledge and Proficiency with Microsoft Office
- Strong data entry skills