Quality Pend Review/Denial Writer

Summary/Position Objectives:
Incumbent is responsible for reviewing pended mismatched claims against prior authorization data and determining the appropriateness of claim submission. Communicates with claims area regarding payment of claim and/or updates authorization appropriately. Also receives information from Medical Directors related to the denial of Prior Authorization requests and drafts denial letters for review and signature of appropriate Medical Director. Maintains data from quality review activities and identify trends and makes recommendations for corrective action and quality improvement.

Responsibilities:
Essential Functions:
Complete reviews of pended claims in a timely manner
Maintain department production standards
Maintain accurate and timely review of authorization denials and coordinate with appropriate medical director
Update system appropriately
Maintain copies of all necessary information
Update system and clinical documentation if the denial is overturned
Assist PA supervisor with daily distribution and monitoring of timeliness on fax receipt and completion
Function in a mentoring and leadership role when answering questions for PA data entry staff
Provide backup on the call center phone queues; processing incoming fax requests for prior authorization and website submissions for Prior Authorization
Assist with education of providers on prior authorization process as needed

ABOUT SCHALLER ANDERSON:

Schaller Anderson administers Medicaid and employer self-funded health plans, and manages behavioral health plans. The company’s suite of services includes member services; provider services; claims processing; information services; financial reporting and analysis; medical management; and grievances and appeals services. Schaller Anderson has also been engaged in several consulting projects for states, health plans and providers. Schaller Anderson and its affiliates have 1,400+ employees nationwide and administer health plans with over 1.6 million members. Recently, the Initiative for a Competitive Inner City and Inc. magazine named Schaller Anderson to the Inner City 100, a list that recognizes the fastest-growing companies in America’s core urban areas. Schaller Anderson placed eighth among 5,000 entries in the Inner City 100 competition and was the only health care management company in the top 10.

The VISION of Schaller Anderson, Inc. is to be recognized as the nation’s foremost managed care resource by providing the highest value management and consulting services throughout the health care continuum.


BENEFITS:

Schaller Anderson team members are provided with countless opportunities to make a real difference and the following compensation/benefits:

* Competitive compensation DOE
* Medical, Dental and Vision insurance
* Employee Assistance Program
* Flexible spending accounts
* On-site fitness center (Phoenix headquarters only)
* Life insurance and accidental death and dismemberment insurance
* Short-term and long-term disability
* Paid holidays, paid time off/paid time off reserve
* 401(k) and profit sharing
* Tuition reimbursement
REQUIREMENTS
Knowledge and Skills:
Incumbent must have advanced oral and written communication proficiency, attention to detail, and ability to multi-task and possess strong organizational skills. Must demonstrate the capacity to establish and maintain constructive business relationships with internal/external customers while maintaining integrity and confidentiality. Aptitude to research, analyze and successfully resolve a broad spectrum of issues. Intermediate skill level with Word and Excel required. Proficient in medical terminology and ICD-9, CPT and HCPC codes. Incumbent must be a positive, professional team player, able to manage project time constraints and work with little supervision.

Education and Work Experience:
Incumbent must have minimum of three years of customer service experience. Must have 2 years experience in the Health Care field. Proficiency in common pc skills/applications.