Schedule: 8:00 a.m. to 5:00 p.m. in the candidate's time zone.
Overview: The Appeals Specialist I is responsible for reviewing and resolving member and provider complaints and communicating resolutions to members and providers (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).
Must-Have Requirements
Dependability
Good grammar skills
Good phone communication skills
Meet the job description criteria
Day-to-Day Responsibilities
Research and respond to Medicare grievances in accordance with CMS regulations (training will be provided)
Comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Managed Care Organization 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 other business partners to determine response; assure timeliness and appropriateness of responses per state, federal, and Managed Care Organization guidelines
Meet 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
Compose all correspondence and appeal/dispute and or grievances 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 relating to claims payment and requests for claim adjustments or requests from outside agencies
Job Qualifications
Required Education:
High School Diploma or equivalency
Required Experience
Minimum of 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
Seniority level
Entry level
Employment type
Contract
Job function
Other
Industries
Staffing and Recruiting
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