New

Data Entry Specialist- REMOTE

TEKsystems
$20.00 / hr
life insurance, sick time, 401(k), retirement plan
United States, Florida, Miami
Jun 25, 2025
Description REMOTE SHIFT: Mon - Friday, 9am - 5pm POSITION OVERVIEW: Client has a backlog of 10,000 appeals and grievances so these Data Entry Reps will be filtering through the appeals and take the following actions.... Summary of Position: Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers in accordance with NCQA, CMS, State and other regulations. Process appeals and grievances to facilitate the accurate administration of benefits and clinical policy; ensure compliance of the appeal and grievance process with all regulatory requirements and NCQA standards. Work as an effective interface between internal and external customers Maintain good member and provider relations Principal Accountabilities: Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals. Determine eligibility, benefits, and prior activity related to the claims, payment or service in question. Provide written acknowledgment of member and provider correspondence. Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, the member's complaint or appeal. Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities. Serve as liaison with EmblemHealth departments, delegated entities, medical groups and network physicians to ensure timely resolution of cases. Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals. Follow-up with responsible departments and delegated entities to ensure compliance. Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan's determination. Monitor daily and weekly pending reports and personal worklists, ensuring internal & regulatory timeframes are met. Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all appeals reviewed through the IRE. Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues. Prepare written responses to all member and provider correspondence that appropriately address each complainant's issues and are structurally accurate. Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending. Additional Skills & Qualifications Relevant Work Experience, Knowledge, Skills, and Abilities 3+ years of related professional work experience. Prior health industry and/or compliance work experience. Additional years of experience/training may be considered in lieu of educational requirements. Excellent verbal and written communications skills. Experience in a managed care/compliance environment. Ability to comprehend and produce grammatically accurate, error-free business correspondence. Customer service experience. Proficiency in MS Office applications (especially word processing, and database/spreadsheet). Excellent product knowledge. Excellent problem solving and analytical skills. Ability to work under pressure and deliver complete, accurate, and timely results. Excellent organization and time management skills. Experience Level Intermediate Level Pay and Benefits The pay range for this position is $20.00 - $20.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: * Medical, dental & vision * Critical Illness, Accident, and Hospital * 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available * Life Insurance (Voluntary Life & AD&D for the employee and dependents) * Short and long-term disability * Health Spending Account (HSA) * Transportation benefits * Employee Assistance Program * Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type This is a fully remote position. Application Deadline This position is anticipated to close on Jul 8, 2025. h4>About TEKsystems: We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company. The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. About TEKsystems and TEKsystems Global Services We're a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We're a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. We're strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. We're building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.