1+ months

Appeals Specialist - Medicare - (125166)

Universal Health Services
Reno, NV 89501
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Job Summary: Under the direction of the Manager of Operations, the Appeals Specialist is responsible for

ensuring the appropriate review, research, processing and responding to written member and provider complaints,

appeals, and grievances. This position is required to apply analytical and critical thinking when reviewing contract

language, benefits and covered services in researching and providing an accurate and appropriate resolution in

accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of

Insurance in accordance with state and federal regulations, company policies and NCQA/HEDIS standards. Compile,

analyze and maintain statistical data and trends to maintain the highest level of standards. Additional responsibilities

include assuming responsibility of the Department in the absence of the Department Manager.

Job Requirements

Regulatory Requirements:

  • Bachelors degree or equivalent work experience.
  • Course work to include English, Grammar and Composition, and Mathematics.
  • Valid Nevada State Health Insurance license is preferred.
  • Two years in a managed care industry preferred, two of which are in a customer service position with proven ability in effectively identifying and resolving customer issues.

Language Skills:

  • Ability to effectively communicate in English, both verbally and in writing.


  • Understanding of claims payment and utilization management process.
  • Excellent organizational, written, oral, communication and human relation skills are essential.
  • Letter writing proficiency with an emphasis on quality and accuracy is most important.
  • Ability to work independently and willingly offers assistance.
  • Must demonstrate knowledge of those State and Federal laws and regulations, company policies and procedures, and NCQA/HEDIA standards applicable to complaints and appeals process.
  • Knowledge of CPT/ICD-9 coding with an understanding of medical terminology.
  • Valid Nevada Drivers license and dependable transportation required.
  • Excellent working relationship with Medical Management staff, Medical Director and Claims Managers as it relates to Member or Provider Appeals/Correspondence.
  • Ability to satisfactorily complete a battery of job related tests

Posted: 2020-02-20 Expires: 2020-04-02

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Appeals Specialist - Medicare - (125166)

Universal Health Services
Reno, NV 89501

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