Employer Industry: Healthcare Services

Why Consider this Job Opportunity:
- Competitive pay
- Opportunity for career advancement and growth within the organization
- Flexible work solutions including remote options and hybrid work schedules
- Comprehensive benefits package including health insurance coverage, 401(k), and tuition reimbursement
- Supportive and inclusive work environment

What to Expect (Job Responsibilities):
- Coordinate and perform all appeal-related duties in a Medicare Advantage Dual Special Needs Plan and Medicare-Medicaid Plans
- Analyze and respond to appeals from members, member representatives, and providers regarding denials for services and denials of payment
- Research and apply pertinent Medicare and Medicaid regulations to determine the outcome of the appeal
- Provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting regulations
- Prepare case files for submission to Independent Review Entity and generate and analyze reporting to determine trends in appeal requests and decisions

What is Required (Qualifications):
- Bachelor's Degree or equivalent professional work-related experience
- 1-3 years of proven Medicare appeals resolution experience in a Managed Care or Healthcare setting
- Demonstrated knowledge of Medicare Advantage, Original Medicare, and Medicaid appeal regulations
- Proficient in using Microsoft Word, Outlook, Access, Excel, and Adobe Pro
- Claims Processing System experience highly preferred

How to Stand Out (Preferred Qualifications):
- Efficient knowledge of CPT, HCPCS, and ICD-9 definitions
- Must be flexible to work in a fast-paced environment and thrive on change
- Outstanding ability to work collaboratively or independently
- Deliver high-quality work and exhibit strong research, communication, and listening aptitude
- Core hours: 8am - 5:30pm Monday - Friday and weekend rotation, as needed

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