Employer Industry: Healthcare Services

Why consider this job opportunity:
- Opportunity for career advancement and growth within the organization
- Competitive benefits and compensation package
- Work in a dynamic and supportive environment focused on member and provider satisfaction
- Engage in meaningful work resolving member and provider complaints
- Chance to contribute to compliance with regulatory standards

What to Expect (Job Responsibilities):
- Conduct comprehensive research and resolution of appeals, disputes, grievances, and complaints from members and providers
- Analyze claims appeals and grievances using support systems to determine outcomes
- Request and review medical records and detailed bills to formulate conclusions
- Communicate resolution effectively to members and providers through written and verbal correspondence
- Prepare appeal summaries and document findings, including trend information if requested

What is Required (Qualifications):
- High School Diploma or equivalency
- Minimum of 2 years of operational managed care experience in a call center, appeals, or claims environment
- Health claims processing background, including coordination of benefits and eligibility criteria
- Familiarity with Medicaid and Medicare claims denials and appeals processing
- Strong verbal and written communication skills

How to Stand Out (Preferred Qualifications):
- Experience with regulatory guidelines for appeals and denials
- Knowledge of provider contracts and fee schedules
- Proficiency in claims processing guidelines and system configurations

#HealthcareServices #ClaimsProcessing #CareerOpportunity #MemberSupport #RegulatoryCompliance

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