Job Title: Appeals Specialist I
Location: 100% REMOTE Candidates must live in one of the preferred 15 states: AZ, FL, GA, ID, IA, KY, MI, MS, NE, NM, NY (outside Greater NYC), OH, SC, TX, UT, WA (outside Greater Seattle), WI.
Work Schedule/Shift & Time Zone: Monday – Friday 8:00 AM – 4:30 PM Candidates will work in their own time zone.
Duration:

Day to Day Job Duties:
Research member complaints. Update system to reflect research completed. Resolve member complaints within the required timeframe.

Job Summary:
Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and providers (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Knowledge/Skills/Abilities:

• Responsible for the comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Client members, providers, and related outside agencies to ensure internal and/or regulatory timelines are met.
• Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
• Request and review medical records, notes, and/or detailed bills as appropriate; formulate conclusions per protocol and work with business partners to determine responses; ensure timeliness and appropriateness of responses per state, federal, and *** guidelines.
• Responsible for meeting production standards set by the department.
• Apply contract language, benefits, and review covered services.
• Contact members/providers through written and verbal communication.
• Prepare appeal summaries, correspondence, and document findings, including trend information if requested.
• Compose all correspondence and appeal/dispute and/or grievance information concisely and accurately in accordance with regulatory requirements.
• Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine the root cause of payment errors.
• Resolve and prepare written responses to incoming provider reconsideration requests related to claims payment, claim adjustments, or requests from outside agencies.

Required Education:

• High School Diploma or equivalent.

Required Experience:

• 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, and knowledge of regulatory guidelines for appeals and denials.
• Strong verbal and written communication skills.