Responsibilities

Prominence Health is headquartered in Reno, Nevada and is a wholly owned subsidiary of Universal Health Services (UHS). We offer HMO, PPO, and Medicare Advantage plans, Administrative Services for self-funded organizations, and Accountable Care Organization (ACO) administration and consulting. We started in Northern Nevada in 1993 and have expanded across Nevada, Texas, Florida, California, and Washington D.C. to serve over 200,000 customers and members with highly competitive plans, physician partnerships, and individualized service. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

Learn more at: https://prominence-health.com/

Job Summary:

Under the direction of the Manager of Operations, the Appeals Specialist is responsible for ensuring the appropriate review, research, processing and responding to written member and provider complaints, appeals, and grievances. This position is required to apply analytical and critical thinking when reviewing contract language, benefits and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of Insurance in accordance with state and federal regulations, company policies and NCQA/HEDIS standards. Compile, analyze and maintain statistical data and trends to maintain the highest level of standards. Additionalresponsibilities include assuming responsibility of the Department in the absence of the Department Manager.

Job Duties/Responsibilities:

• Responsible for receiving all member appeals and setting up files. Initiates telephone calls to obtain information and clarification of information. Interfaces with other departments, reviews medical records or other pertinent documentation and ensures all necessary information is obtained in order for the Appeals Committee to base a rationale for determination.

• Prepare appeal packet that includes documentation, supportive material pertaining to appeal. Distribute prior to appeal meeting. Present member appeals to the Appeals Committee within established timeline.

• Communicate accurate written responses to members conveying the Appeals Committees decisions within established timelines set by state and federal regulations, company policies, and NCQA standards to avoid punitive fines.

  Benefit Highlights:

• Loan Forgiveness Program

• Challenging and rewarding work environment

• Competitive Compensation & Generous Paid Time Off

• Excellent Medical, Dental, Vision and Prescription Drug Plans

• 401(K) with company match and discounted stock plan

• SoFi Student Loan Refinancing Program

• Career development opportunities within UHS and its 300+ Subsidiaries! · More information is available on our Benefits Guest Website: benefits.uhsguest.com

  About Universal Health Services:

  One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

  Qualifications

  Qualifications and Requirements:

• Associate degree or equivalent work experience.

• Course work to include English, Grammar and Composition, and Mathematics.

• Valid Nevada State Health Insurance license is preferred.

• Two years in a managed care industry preferred, two of which are in a customer service position with proven ability in effectively identifying and resolving customer issues.

• Ability to effectively communicate in English, both verbally and in writing.

• Understanding of claims payment and utilization management process.

• Excellent organizational, written, and oral, communication, and human relation skills are essential.

• Letter writing proficiency with an emphasis on quality and accuracy is most important.

• Ability to work independently and willingly offers assistance.

• Must demonstrate knowledge of those State and Federal laws and regulations, company policies and procedures, and NCQA/HEDIS standards applicable to complaints and appeals process.

• Knowledge of CPT/ICD-10 coding with an understanding of medical terminology.

• Valid Nevada Driver’s license and dependable transportation required.

• Excellent working relationship with Medical Management staff, Medical Director and Claims Managers as it relates to Member or Provider Appeals/Correspondence.

• Ability to satisfactorily complete a battery of job related tests

  EEO Statement

  All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

  We believe that diversity and inclusion among our teammates is critical to our success.

  Avoid and Report Recruitment Scams

  At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS

  and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

  If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

  If you would like to learn more about the opportunity, please contact Bridget Gomez at: bridget.gomez@uhsinc.com