Job Detail

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

• Properly distinguishes between a provider dispute and a provider appeal. Confirm each provider appeals are correctly identified for appropriate tracking and reporting

• Updates tracking system to ensure cases are processed timely and appropriate actions are taken

• Reviews and processes provider appeal and dispute determinations according to CMS, contractual and processing guidelines. Issue appropriate documentation and payments accurately and timely.

• Corresponds with delegated entity as needed to obtain appropriate records or payment information

• Prepares appropriate documentation and submit to IRE when provider appeals result in adverse determination and/or untimely. Ensure IRE responses requiring effectuation are processed timely and accurately.

• Processes/Adjudicates claim(s) according to departmental procedures

• Meets and consistently maintains quality and productivity standards as defined by the Management.

• Identifies denial or payment variance trends and escalates to department management as appropriate for training opportunities and corrective action.

• Assists in preparing and reviewing cases for regulatory and other health plan audits.

• Actively participates in ongoing training to support company and department initiatives.

• Supports department initiatives in improving processes and workflow efficiencies

• Adheres to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.

• Complies with company’s time and attendance policy.

• Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.

• Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.) and teamwork.

• Performs additional related duties as assigned by Management

• Minimum Experience:

• Education/Licensure:

• Other: