Appeals & Grievances Specialist (Remote)

Quick Facts

• Role: Appeals & Grievances Specialist (Remote)

Description

Provides support for claims activities by reviewing and resolving member and provider appeals, disputes, grievances, and complaints, then communicating resolutions in line with CMS standards and other applicable requirements. Researches claims appeals and grievances, reviews medical records and billing as needed, and prepares compliant, accurate written correspondence and summaries. Meets departmental claims production standards and supports timely responses per state, federal, and organizational guidelines.

Responsibilities

• Research and resolve appeals, disputes, grievances, and/or complaints while meeting internal and regulatory timelines

• Use support systems to determine appropriate outcomes for claims appeals and grievances

• Request and review medical records, notes, and/or detailed bills; formulate conclusions per protocol

• Apply contract language, benefits rules, and covered service review to the claims review process

• Contact members/providers as needed via written and verbal communication

• Prepare appeal summaries and correspondence and document findings (including trend information when requested)

• Compose accurate, concise appeal/dispute/grievance correspondence in compliance with regulatory requirements

• Research claims processing guidelines, provider contracts, fee schedules, and system configurations to identify root causes of payment errors

• Resolve and prepare written responses to provider reconsideration requests related to claim payments, claim adjustments, and requests from outside agencies

Benefits

• Competitive benefits and compensation package

Requirements

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment (or equivalent education and experience)

• Health claims processing experience including COB, subrogation, and eligibility criteria

• Experience with Medicaid and Medicare claims denials and appeals processing; knowledge of regulatory guidelines

• Customer service experience

• Strong organizational and time management skills

• Effective verbal and written communication skills

• Proficiency with Microsoft Office and applicable software program(s)

Preferred Qualifications

• Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace, or other government-sponsored programs) or in a medical office/hospital setting

• Completion of a health care related vocational program (e.g., certified coder, billing, or medical assistant)