Appeals Specialist in Columbus, OH at Pionear

Date Posted: 7/23/2020

Job Snapshot

  • Employee Type:
  • Location:
    Columbus, OH
  • Job Type:
  • Experience:
    At least 2 year(s)
  • Date Posted:

Job Description

Pionear is seeking professional individuals with a background within the healthcare industry. Someone with at least 1 years of experience within Medical Appeals would be the preferred experience. Our healthcare clients in the Columbus OH area are always looking to find the next best talent. Please review the description below and apply if interested.


  • Manages submission, intervention and resolution of appeals, grievances, and/or complaints from members and related outside agencies as a part of the integrated Healthcare Services Team
  • Conducts pertinent research, evaluates, responds and completes appeals and other inquiries accurately, timely and in accordance with all established regulatory guidelines. Prepares appeal summaries and correspondence and documents information for tracking/trending data.


Essential Functions:

  • Enters denials and requests for appeal into information system and prepares documentation for further review.
  • Researches issues utilizing systems and clinical assessment skills, knowledge and approved Decision Support Tools in the decision making process regarding health care services and care provided to members
  • Assure timeliness and appropriateness of all Provider appeals according to state and federal and Healthcare guidelines
  • Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research
  • Evaluates for medical necessity and appropriate levels of care and formulates conclusions per protocol.
  •  Collaborates with Medical Directors and other team members to determine appropriate responses
  • Obtains Medical Director approval for determination per protocol
  • Work with Customer Service to resolve balance bill issues and other member complaints regarding providers
  • Prepare responses to provider grievances / appeals.


Job Requirements

Required Experience:

  • 0-2 years of Utilization Review experience and Managed Care experience.
  • Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials


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