Appeals Specialist II

The Appeal Specialist II will manage cases returned from clinicians to the Resolution queues in TruCare after clinical review completion. This role is responsible for reviewing the outcome in TruCare and documenting clear payment or denial instructions in CenPAS through a Pulse Note, based on the authorization or appeal status. The coordinator will also review cases routed with the reason “Corp UM In Clinical Review” to determine if a clinician failed to send the task or if the case remains pending clinical review. Daily responsibilities include collaborating with internal partners, ensuring accurate case routing, maintaining compliance with turnaround time standards, and supporting process improvement initiatives. Years of experience required: 1-2 years prior auth, referrals, claims resolutions and disputes and reconsiderations. UM experience. Top 3 must-have hard skills stack-ranked by importance 1 Knowledge of Prior Authorizations / UM 2 Knowledge of Claims Resolution & Disputes / Claims Reconsiderations 3 Multi-tasking skills (multiple systems at once), literate, computer knowledge, typing skills / internet speed a MUST
salary: $22.99 - $23 per hour
shift: First
work hours: 8 AM - 5 PM
education: High School
Responsibilities
The Appeal Specialist II will manage cases returned from clinicians to the Resolution queues in TruCare after clinical review completion.
This role is responsible for reviewing the outcome in TruCare and documenting clear payment or denial instructions in CenPAS through a Pulse Note, based on the authorization or appeal status.
The coordinator will also review cases routed with the reason “Corp UM In Clinical Review” to determine if a clinician failed to send the task or if the case remains pending clinical review.
Daily responsibilities include collaborating with internal partners, ensuring accurate case routing, maintaining compliance with turnaround time standards, and supporting process improvement initiatives.
Skills
- Prior Authorizations
- Claims Resolution
- Multi-tasking
Qualifications
- Years of experience: 1 year
- Experience level: Experienced
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Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).
This posting is open for thirty (30) days.
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