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Specialist, Appeals & Grievances
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Job Description
- Req#: 300001460683308
Employer Industry: Healthcare Services
Why consider this job opportunity:
- Opportunity for career advancement and growth within the organization
- Competitive benefits and compensation package
- Work collaboratively in a supportive environment
- Engage in meaningful work by resolving member and provider concerns
- Ensure compliance with state and federal healthcare regulations
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, notes, and detailed bills to formulate conclusions
- Prepare appeal summaries and correspondence, ensuring compliance with regulatory requirements
- Resolve and respond to incoming provider reconsideration requests regarding claims payments
What is Required (Qualifications):
- High School Diploma or equivalent
- Minimum 2 years of operational managed care experience in a call center, appeals, or claims environment
- Background in health claims processing, 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 with regulatory guidelines for appeals and denials
- Knowledge of claims processing guidelines, provider contracts, and fee schedules
#HealthcareServices #ClaimsProcessing #MemberSupport #CareerOpportunity #EqualOpportunityEmployer
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