Position Purpose Supports the documentation and processing of appeals, disputes and reconsiderations to ensure they are in accordance with state and National Committee for Quality Assurance (NCQA) requirements. Support the team to ensure appeals, disputes and reconsiderations are reviewed and processed timely. Education/Experience Requires a High School diploma or GED. Requires 1 – 2 years of related experience. Knowledge of appeals, disputes and reconsiderations process preferred. Performs data entry to support the tracking, logging, and processing of appeals, disputes and reconsiderations in accordance with established regulatory and accreditation guidelines and procedures Prepares correspondence for appeals, disputes and reconsiderations and maintains documentation files Reviews and investigates appeals, disputes and reconsiderations requests to determine applicable follow up Conducts research needed to evaluate, process, and respond to appeals, disputes and reconsiderations to ensure a timely decision Prepares case files including supporting documentation and determinations needed to review, process, and report the appeals, disputes and reconsiderations Gathers appeals, disputes and reconsiderations data to track and report on trends and final outcomes to team including conducting outreach for an update on statuses, determinations, and explanations Performs other duties as assigned Complies with all policies and standards EEO “Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.” =============== Story Behind the Need What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative? Multiple Health Plans – Medicaid LOB only Transfer and evaluate cases from CenPAS and review provider disputes / reconsideration requests from providers/facilities Modify authorizations Respond to claims/UM Describe the performance expectations/metrics for this individual and their team: Dependent upon assigned role Tell me about what their first day looks like: Meet with leaders and start learning system/processes What previous job titles or background work will in this role? Utilization Management Billing/coding (typically found in medical practices/facilities) Claim processing Reason for request is to backfill a Beeline position that recently became available in June 2025. Any future projected positions potentially coming up? NO If yes, note: unknown at this time Typical Day in the Role Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique? Remote with virtual assistance. Teams/Camera/Huddles and 1:1 with Leadership. Candidate will review cases in CENPAS and claims in the AMISYS system to determine resolution on provider reconsiderations. After full training, the performance metric is to complete 50 case reviews each day with a 95% or better overall monthly Quality average. The ability to gain knowledge in multiple Health Plans. Candidate Requirements Education/Certification Required: High School Diploma/ GED Preferred: N/A Licensure Required: N/A Preferred: N/A Years of experience required: 2 years appeals, claims, authorizations Must haves: Knowledge with reviewing claims and authorizations, familiar with TruCare, Amisys Disqualifiers: poor attendance Additional qualities to look for: fast learner, open to feedback, team player Top 3 must-have hard skills stack-ranked by importance 1 Data Entry/ Typing 40 wpm 2 Knowledgeable with Claims/Coding 3 Knowledgeable with Authorizations Candidate Review & Selection Shortlisting process Candidate review & selection Interview information Onboard process and expectations Projected Manager Candidate Review Date: 1-2 days post shortlisting Type of Interviews Teams- Cameras On Required Testing or Assessment (by Vendor): Typing test, basic computers skills test Next Steps Do you have any upcoming PTO? N/A Colleagues to cc/delegate Myriam Guadiola-Gonzalez