Lab Technician

UST HealthProof is a partner for health plans, offering an integrated ecosystem designed to streamline health plan operations. Our BPaaS solutions efficiently manage complex administrative tasks, enabling our clients to focus on members' well-being. Guided by our values of simplicity, integrity, and leadership, we collaborate with our customers to provide accessible and affordable healthcare for all. With a global team of over 4,000 professionals, our brand stands on a solid foundation of people-centricity and ethical leadership. We remain committed to easing the burdens of healthcare and advancing equitable access.

Position Overview:

• Collaborate with the Appeals & Grievances (A&G) team to review medical records, documentation, and claims data, determining the need for medical necessity reviews and resolving coding discrepancies or claim denials.
• Provide expertise on claims processing in accordance with regulatory requirements and plan-specific policies.
• Demonstrate a comprehensive understanding of appeals processes and relevant plan policies.
• Maintain thorough knowledge of medical coding systems and payer-specific protocols, ensuring accurate claim processing and compliance with federal and state regulations, including CMS guidelines.
• Stay abreast of changes in coding guidelines, industry standards, and regulatory updates
• This position description outlines the typical responsibilities and duties expected of this role; additional essential functions may be assigned as needed

Qualifications:

• Bachelor's degree in Business Administration, Economics, Healthcare, Information Systems, Statistics, or related field required. A relevant combination of education and experience may substitute for a degree
• Must have valid / active professional coding certification
• Prior experience in a grievance and appeals environment, specifically adherence to CMS regulations
• Familiarity with medical benefits, health care industry regulations, claims, authorizations, and Medicare Advantage plans
• Experience working within or with Medicare Advantage plans and Independent Review Entities
• Expertise in CMS regulations pertaining to Medicare Advantage and related appeals and grievance procedures

Skills & Competencies:

• Demonstrated problem-solving abilities with the capacity to apply knowledge across corporate departments
• Excellent communication skills for interpreting and conveying information effectively
• Strong analytical, organizational, planning, and strategic thinking skills
• Ability to interact professionally with personnel at all levels of the organization
• Proficiency in defining issues, collecting and analyzing data, and drawing sound conclusions
• Proven record of delivering results and contributing to organizational success
• Dedicated customer service orientation
• Capability to perform in a fast-paced environment and consistently meet deadlines

Appeals and grievances,Healthcare,medical benefits,Claims processing,Medicare advantage plan,Medical Coding,CMS regulations