Appeals Specialist

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. 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. Additional responsibilities include assuming responsibility of the Department in the absence of the Department Manager.

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 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.

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