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Specialist, Appeals & Grievances
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Job Description
- Req#: 300001375210001
Employer Industry: Healthcare Services
Why consider this job opportunity:
- Opportunity for career advancement and growth within the organization
- Competitive benefits and compensation package
- Supportive and collaborative work environment
- Chance to make a positive impact on member and provider experiences
- Engaging work that involves resolving appeals and grievances
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 to determine outcomes using support systems
- Request and review medical records and detailed bills to formulate appropriate responses
- Communicate with members and providers through written and verbal correspondence
- Prepare appeal summaries and document findings in accordance with regulatory requirements
What is Required (Qualifications):
- High School Diploma or equivalency
- Minimum 2 years of operational managed care experience (call center, appeals, or claims environment)
- Health claims processing background, including coordination of benefits, subrogation, 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 in a healthcare-related service environment
- Knowledge of regulatory guidelines for appeals and denials
#HealthcareServices #MemberExperience #CareerOpportunity #ClaimsProcessing #ManagedCare
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