Appeals Referee Job Description Samples

Results for the star of Appeals Referee

Adult Soccer Referee

Adult Soccer Referee - $25.00 per hour - 8 Positions.Position runs from April to the middle of May (Soccer season, April 3, 2017 - May 15, 2017). Referees are responsible for providing a positive and safe environment for Adult Soccer recreation games. Applicants must possess excellent communication skills, energetic personalities and the ability to work patiently with participants.

This position requires applicants with a working knowledge of the rules of soccer and at least three (3) years of playing experience. Referees must have the ability to interpret and enforce the rules of soccer and must be able to physically keep up with the speed of play.Equal Opportunity Employer.

Use this job description

Sports Official/ Referee

Level: Experienced Job Location: USA-NC-Hendersonville Position Type: Seasonal Education Level: Not Specified Job Shift: Hours Vary Salary Range: $9.00 - $20.00 Hourly Travel Percentage: Undisclosed Job Category: Nonprofit - Social Services

Use this job description

Intramural Referee

Job Description Summary: Job ID = 740.

Assist with the on ice facilitation of the Goggin Ice Center Intramural Sports Program in accordance with the Goggin Ice Center Intramural Rule Books. Assist the Intramural Supervisors and Scorekeepers with pre and post game operations. Provide unbiased and emotionally controlled judgment calls throughout the course of each game.

Officiate intramural ice hockey and broomball games and other supports/events as assigned. Keep score and operate scoreboard as needed. Other duties as assigned.

Minimum Qualifications: Skating experience preferred. Experience in ice related sports and activities is preferred. Knowledge of ice hockey and/or broomball is desired; training is available.

Working Title: Intramural Referee Department: Goggin Ice Center Division: Finance & Business Services Campus: Oxford Posting Date: 11/22/2016 Job Category: Student Position Group: Student Hourly Student Pay Grade Minimum: 8.15 For Inquiries for Posting, Contact: Ben Chuha Posting Inquiries Contact Information (phone, email...): Application Types Accepted: Student Application Criminal Background Check Required: No

Use this job description

Manager, Denials & Appeals (Rn) – Austin

Manager, Denials & Appeals (RN) – Austin
Joining this team means you'll be surrounded by colleagues who are dedicated to meeting their own high standards, to inspiring their teammates and to making a positive impact on under-insured and uninsured individuals. The group is a fast, agile, customer-focused organization with a commitment to implementing the latest technologies. If these same things get you excited, we hope to hear from you.
Position Purpose: Ensure appropriate processing of member denials and appeals, provider appeals that require clinical review, and/ or State Fair Hearings. Perform duties as the point of contact with the State.

Job Description:

  • Ensure that all denials and appeals are processed in accordance with Federal, State and NCQA time frames and other contractual legal requirements
  • Identify trends within denials and appeals and provide results to internal committees, CMS and the State as required by contract
  • Serve as the point of contact for any issues or questions related to denials and appeals for various external agencies, including state, local and federal governments, local community and the public
  • Integrate federal and state law changes to denials and appeals into company's regulatory system
  • Recommend solutions and ensure issues are corrected and corrective measures are implemented to prevent recurrences
  • May provide training and direction to agencies in developing procedures to comply with denials and appeals requirements


  • Bachelor's degree in Nursing or related clinical field or equivalent experience.
  • 3+ years of utilization management, quality improvement or denials and appeals experience.
  • Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
  • Managed care, healthcare law or compliance experience preferred.
  • Texas RN (Registered Nurse)
Our client offers options that allow you to do more than just plan for retirement. Their programs allow shared success with employees.
  • 401(k) with company match
  • Employee stock purchase plan
  • Training and Learning Opportunities/Tuition Reimbursement/Educational Assistance
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location
Equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Use this job description

Phoenix Appeals & Grievances RN - Managed Care

Appeals & Grievances Nurse (RN) – Managed Care
Phoenix, AZ
Job Summary:

The Quality Improvement Appeals & Grievances Nurse performs all aspects of the Quality Management Program, including the grievances and appeals process, performance improvement, accreditation and regulatory requirements, and all related activities, objectives, and analysis. The nurse supports the organization by working to resolve provider payment disputes through advanced and complicated case review of the appropriateness of medical care requiring considerable clinical judgment, independent analysis, and detailed knowledge of managed care and organizational guidelines.    The nurse is responsible for oversight and execution of the grievance and appeals process, which includes coordinating the investigation among departments, analysis of root causes, collaborating with staff to develop corrective action plans, and monitoring corrective action taken. Manages the consolidation of the complaints and grievance activities on a quarterly basis, and prepares monthly, quarterly and annual reports on assigned quality improvement activities.
Your Reward: 
This growing organization is committed to the health and happiness of all their staff. They offer a comprehensive benefits package to all full-time, permanent employees including zero cost health insurance plan, dental, vision, and life insurance, wellness programs, tuition assistance, matching 401(k) with instant vesting, on site gym and cafeteria, company-wide annual bonus (10%-13% of salary), generous PTO plus paid holidays, and much more!
Your Background:
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
Roughly 2-5 years acute care clinical nursing experience is required.
At least 1 year previous experience in Denials & Grievances & Appeals, Utilization Review in a Managed Care Organization.
Around 2-4 years of recent experience at a health plan or other Managed Care Organization (HMO/TPA/IPA/etc).
Requires 1-3 years of customer service experience communicating directly with members to identify their true complaint and obtain any additional information to resolve their case.
Understand Utilization Review guidelines, Medicare and Medicaid regulations, and appropriate state plan requirements.
Experience using standardized clinical guidelines, preferably InterQual, is required.  Must be able to differentiate between PCP rendered care and specialty care; and be able to identify clinical quality of care issues.
Possess excellent communication and interpersonal skills; in person, over the phone, and in writing.
Able to work independently and multitask, handling multiple projects and prioritizing workflows.
Your Duties:
Facilitates continuous improvement in the health plan delegated networks by providing individualized case review and processing.  Performs clinical review related to Grievances, Appeals, Quality Referrals and Occurrences by identifying the issues of the case, ordering and collecting needed documents or records, reviewing the case documents, completing a case summary, and either leveling or reviewing the case with the Medical Director or CMO as appropriate.  Coordinates and submits results of focused review studies, medical record audits and HEDIS results as appropriate. 
Acts in the capacity of member advocate addressing member or provider concerns, maintaining absolute file integrity with regards to content, location, and confidentiality.  Conducts clinical review and evaluation of member and provider complaints, grievances and appeals using considerable clinical judgment, evidence based standards, independent analysis, knowledge of operational policies, clinical guidelines, plan benefit structures and regulatory requirements to determine the appropriateness of care provided.  Reviews, triages and prioritizes cases to meet required turnaround times.  Ensures that appeals and grievances are categorized and processed within appropriate state and federal time frames. Interacts with external partners, including providers, medical groups, IPAs and other external vendors to obtain additional information to resolve the member's case.   Interaction includes preparing for and participating in regulatory site visits.  Performs research and analyzes complex issues.  Identifies potential quality issues and initiates investigations, processing any substantiated quality of care issues.  Summarizes cases including articulation of member's perception, initial denial determination and notification, analysis of medical records, and appropriate application of all applicable policies, guidelines, benefit plans and laws, rules and regulations. 
Maintains strict compliance with federal, state and NCQA requirements and guidelines.  Participates in and coordinates Quality Management committee activities by assisting with development of the agenda, providing the assigned meeting documents, and presenting reports.  Provides complete and accurate documentation of work performed by entering data into specified databases or forms as instructed and reporting any required metrics.  Participates in the Quality Management process by identifying problems, examining solutions options, implementing action plans and by coordinating, facilitating and/or participating in inter and intradepartmental quality initiatives and work groups.

Use this job description

Claims Appeals

About us:
Morgan Stephens represents the nation’s top healthcare systems offering the highest compensation and benefits to our top candidates.   We are created and managed by experienced industry professionals in healthcare. As a leading provider of contract, contract to perm, and direct placement recruiting services to healthcare organizations throughout the United States, we have successfully served the needs of our employees and clients by placing thousands of quality healthcare professionals into organizations seeking top talent.
Open Position:
We are looking for candidates with strong customer service and interpersonal skills, the ability to multi-task, who are detail oriented, have a desire to help others, and who are excited to grow and develop a career.  A Claims Appeals Specialist performs detailed review and analysis to investigate audit requests from Medicare Recovery Audit Contractors. Determines why a claim is under review, in dispute, or was denied. Coordinates with various internal departments ensuring all appropriate documentation is obtained in order to respond to audit requests appropriately.
Ensures all requests for patient information meets applicable HIPAA requirements before information is shared.
Requests copies of the medical records and corresponding claims.
Analyzes information obtained to identify discrepancies and anomalies determining if services were properly documented and properly billed.
Documents any findings resulting from the claim review and determines if a remedy is available to address the finding.  If a remedy is appropriate, works with client to implement remedy according to all applicable external requirements and internal policies.
Ensures necessary repayments are completed by the appropriate party for any identified payment discrepancies.
Interprets and understands health insurance appeals and provider dispute resolution processes, applicable clinical guidelines, and health payer coverage policies in order to effectively prepare claim packages nt procedures are followed.
Maintains current knowledge of operational and billing policies, practices, and references
Responds to inquiries and/or reports of billing concerns, noncompliance with company policy and procedure taking the appropriate actions as required.
More Information:

Morgan Stephens ofrecemos reclutadores que hablan Espanol

Use this job description

Registered Nurse - Appeals

We’re working on behalf of a NYSE-listed company in Tampa that focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage, and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs.  The company serves approximately 3.8 million members nationwide through its quality and cost-effective health care solutions, and is committed to continually improving the quality of care and service its provide to its members, helping them access the right care at the right time in the appropriate setting.
We seek candidates with inpatient experience within an acute care clinical setting (Med Surge, Telemetry, ER or ICU) for the role of Appeals Reviewer.  In this role you will be responsible for preparing cases for physician review and all appeal related activities accurately, efficiently, and within mandated timeline requirements.  You will perform appeal reviews on medical and/or behavioral health records and cases utilizing established guidelines and member benefit plans.  You will communicate the outcome of the appeals process with members, internal and external partners.  You will utilize company designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with appeal determinations.  You will collect information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process.  
Candidates must be a graduate of an accredited school of nursing and be licensed as an RN or LPN in the state of Florida.  Must have two (2) or more years of experience in an acute care clinical setting with general nursing exposure in UM to include pre-auth.   Must have two (2) or more years in Managed Care experience.  Must have working knowledge of InterQual criteria.
Competitive compensation and benefits.   This is an excellent opportunity to join an organization employs more than 7000 employees across the country, and fosters a rewarding and enriching culture that inspires its associates to do well for others and themselves.  For more information call 941.739.1400 or submit your resume now by clicking on the button below that says “Apply Now.”

Use this job description

Clinical Appeals Nurse- US Telecommute (Full-Time)

Clinical Appeals Nurse- US Telecommute (Full-time) (Job Number: 1705004358)DescriptionConifer Health Solutions is a leading healthcare business process management services provider working to improve operational performance for more than 600 clients so they can support financial improvement, enhance the patient experience, and drive value-based performance. Through our revenue cycle management, patient communications, and value-based care solutions, we empower healthcare decision makers—hospitals, health systems, physicians, self-insured employers, and payers—to better connect every point of care and wellness management.

  Are you ready to be part of our solutions?  Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!     JOB SUMMARY   The Revenue Cycle Clinician for the Appellate Solution is responsible for:

Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review Preparing and documenting appeal based on industry accepted criteria     ESSENTIAL DUTIES AND RESPONSIBILITIES Others may be assigned.   Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal.

Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization. Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process. Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual®, as evidenced by Inter-rater reliability studies and other QA audits.

Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs), eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office. Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.

Additional responsibilities: Serves as a resource to non-clinical personnel Provides CRC leadership with sound solutions related to process improvement Assist in development of policy and procedures as business needs dictate Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.QualificationsKNOWLEDGE, SKILLS, ABILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.   Demonstrates proficiency in the application of medical necessity criteria, currently InterQual® Possesses excellent written, verbal and professional letter writing skills Critical thinker, able to make decisions regarding medical necessity independently Ability to interact intelligently and professionally with other clinical and non-clinical partners Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms Ability to multi-task Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process Ability to conduct research regarding off-label use of medications     EDUCATION / EXPERIENCE Include minimum education, technical training, and/or experience required to perform the job.   Must possess a valid nursing license (Registered or Practical/Vocational) Minimum of 5 years recent acute care experience with the last 2 years in a facility environment Medical-surgical/critical care experience preferred Minimum of 2 years UR/Case Management experience within the last 2 years Managed care payor experience a plus either in Utilization Review, Case Management or Appeals Patient Accounting experience a plus Previous classroom led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred     CERTIFICATES, LICENSES, REGISTRATIONS   Current, valid RN/LPN/LVN licensure Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred     PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.   Ability to lift 15-20lbs Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews     WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.     OTHER   May require travel – approximately 10% Interaction with facility Case Management, Physician Advisor is a requirement

Primary Location: TX-DallasOrganization: 238-Conifer

  • Dallas

  • TX

Use this job description

Payer Audits & Appeals Coordinator


Work where you make a difference! If you’re looking for a place where you can grow in your personal life, in your career, and in your community, St. Luke’s may be just the place for you. A strong, talented staff is at the heart of St. Luke’s Health System. We are the state’s largest employer with more than 13,500 employees and a medical staff of more than 1,800 physicians and advanced practice clinicians. Our employees are dedicated to impacting the lives of those in our community while pursuing a life- changing career at St. Luke’s. Our staff is the reason for our outstanding reputation as both a quality employer and superior healthcare organization. We’re proud of our people who deliver skilled, compassionate care every day, and are looking to add dedicated individuals who will continue in the same tradition of excellence. With multiple locations in the beautiful southern and central Idaho, our mild, four season climate means you can play outdoors year-round. Whether you prefer leisurely walks along the river or heart-pounding climbs up a sheer cliff- there is always something to do after work. An exciting mix of urban and outdoor life defines Idaho’s culture, you can ski in the morning and watch a college sporting event at night. It is a great state to raise a family and forge lasting relationships. The cost of living is low, and quality of life is high. St. Luke’s Health System has an exciting opportunity for

Coordinator Payor Audits and Appeals to join our team!


Coordinator Payor Audits and Appeals The Coordinator Payor Audits and Appeals designs processes across the facilities in St. Luke’s Health System to respond appropriately and in a timely manner to record requests from all payors that are, or could be, related to audits and payor recovery activities (RAC, certs, probes, etc.). Monitors and coordinates St. Luke’s response (including appeals) to all payor recovery activities. In cooperation with the Coordinator Physician Compliance Coding and the Coordinator Hospital Compliance Coding, the Coordinator Payor Audits and Appeals makes recommendations to clinical areas, the HIM Departments, Coding Departments and the Billing Departments to address issues raised through payor recovery activities. The Manager reports to the Reimbursement Integrity Officer.


Required Criteria + BA/BS, CPC or CCS required

  • A minimum of 3 years experience in a healthcare environment related to CMS and 3rd party payor audits and appeals.

  • A minimum of 3 years experience in physician and hospital coding and/or medical record documentation.

  • A minimum of 3 years management experience.

  • A minimum of 3 years experience in overseeing hospital and physician responses to payor recovery activities.

Preferred Criteria + RHIA/ RHIT or MA/MS preferred

  • Excellent working knowledge of payor recovery processes required.

  • Excellent working knowledge of CPT, HCPCS, APC and DRG codes.

  • Thorough understanding of CMS and other payor documentation, compliance, reimbursement and coding requirements.

  • General understanding of hospital and physician practice operations.

  • Proficiency with third party billing and documentation standards, particularly medical necessity and the evaluation and management codes is essential.

  • Must be capable of reading and understanding inpatient and outpatient medical records and billing directly from the same Our employees enjoy many benefits, some of the most popular aretuition reimbursement, hospital retirement contributions, and hospital-supported on-going training and education. __________________ #One of American’s Top 15 Health Systems - U.S.News & World Report, "America's Best Hospitals 2015-2016"*St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.



Position TypeRegular Full-Time

Work ScheduleDAY

Location NameBoise

Requisition ID2017-4786

Use this job description

Appeals Specialist

Description: HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can email us here to request reasonable accommodations. Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "my account" and click on "View your job submissions". BASIC FUNCTION:Under supervision, this position is responsible for processing, organizing, and coordinating all materials and information relating to processing appeals for all lines of business following federal, state, and accreditation requirements; and for accurately responding by telephone, in person, or through correspondence to all inquiries involving requests for appeals from members, the Department of Labor, or ERISA; sending acknowledgement letter to member and draft provider letters for directors signature; entry of appeals into appropriate database; and processing of internal quality of care referrals. JOB REQUIREMENTS:* 2 years experience researching and responding to telephone and/or correspondence inquiries regarding health insurance claims/services OR 1 year health insurance plus 2 years of customer service experience.

  • Effective analytical, problem solving and research skills.

  • Effective organizational skills to accommodate large volume of reference materials combined with time management skills to achieve accessibility to callers.

  • Effective verbal and written communication skills to include the ability to clearly express oneself in a well-modulated tone with correct grammar and attention to enunciation. PREFERRED JOB REQUIREMENTS:* BlueChip claims payment experience.

  • Medical terminology. Knowledge of appeals processing.

  • Ability to think clearly and maintain a professional, poised attitude under pressure.

  • Detail oriented.

  • Bi-lingual Spanish speaking Location: IL - Chicago Activation Date: Wednesday, January 25, 2017 Expiration Date: Monday, May 8, 2017 Apply Here

Use this job description