• Denials Specialist

    Job Location US-MI-Detroit
    Job ID
    Utilization Management
    Business Line
    CMC Corporate
  • Overview

    Who we are:

    Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.


    We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.


    Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.


    A Day in the Life of a Denials Specialist:

    This position requires advanced knowledge of all lines of business for MHP including Medicare, Commercial and National Committee for Quality Assurance (NCQA), URAC or general accreditation requirements to collaboratively work with other MHP departments. This position will coordinate MHP’s denial notification process and maintain accurate and timely tracking and reporting in accordance with federal and state laws and department policies.


    • Coordinate and process all denial determinations
    • Track all denial data components as required by MHP and regulatory and accrediting agencies
    • Regularly provide written reports of compliance with denial notification standards
    • Conduct monthly internal audits of denial process to assure compliance with staff time frame standards and report results to manager
    • Draft denial letter templates
    • Identify and implement process improvement opportunities
    • Function as a liaison between the Utilization Management department and the Member Services Case Specialists
    • Document user requirements for MCS systems development
    • Analyze the data elements of denial reports
    • Draft and update policies and procedures pertaining to the denial process
    • Remain updated on all relevant policy changes made by MHP
    • Remain updated on all relevant regulatory and accreditation reporting requirements and policy changes


    What you can bring to Meridian:

    • Associate’s degree is required
    • Bachelor’s degree or Fellow designation from the Academy of Healthcare Management (AHM) is preferred
    • A minimum of one to two years’ experience as a Utilization Management Specialist or one to two years of related health industry experience is required

    What Meridian can offer you:

    • Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • Meridian offers 401k matching that is above the national average.
    • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
    • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.


    Equal Opportunity Employer



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