Job ID: J133551
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Part time
Job Type: Regular
Posted at: Oct 31, 2018
The job conducts and documents thorough investigations of Part C, Part D, QIO and Administrative Law Judge Case Types, communicating resolution to members in accordance with Center for Medicare and Medicaid Services (CMS) requirements. Requires broad knowledge of plan products, medical policy requirements, processes and enrollment rules. Responsible for all aspects of Part C and D clinical appeals , up to and including decision making, considering potential impacts to regulatory compliance as well as CMS star ratings. Provides support to non-clinical appeals and ensures correct authorization of services.
WV RN License (within 3 months after hire)
Knowledge, Skills & Abilities:
Referral Bonus Level: 1
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