Location: 100% Remote - Preference to candidates in Pacific Time Zone
Summary: As an Appeals Specialist, you play a critical role in reviewing and resolving member and provider complaints. Your responsibility includes ensuring that resolutions align with the standards and requirements set by the Centers for Medicare and Medicaid Services (CMS). With a minimum of 2 years of related experience, you will be a valuable asset in maintaining compliance and upholding the highest standards of service.
Essential Functions
Review and resolve member and provider complaints in accordance with CMS standards and requirements.
Effectively communicate resolutions to members, providers, or authorized representatives, ensuring clarity and understanding.
Maintain detailed records of all complaints and resolutions for tracking and auditing purposes.
Stay informed about the latest CMS guidelines and regulations related to complaint resolution and ensure adherence.
Participate in quality assurance activities to enhance the effectiveness and accuracy of the resolution process.
Identify opportunities for process improvement and contribute to enhancing the overall efficiency of the appeals process.
Knowledge/Skills/Abilities
2+ years of related experience in complaint resolution or appeals within the healthcare industry.
Familiarity with CMS standards and requirements related to complaint resolution.
Excellent verbal and written communication skills to effectively convey resolutions to members and providers.
Keen attention to detail to maintain accurate records and ensure compliance.
Strong problem-solving skills to address complaints effectively.
Ability to adapt to changing guidelines and procedures.
Collaborative and able to work as part of a team to achieve common goals.
Work Arrangement
Monday to Friday
Shifts from 7:30 AM to 4 PM or 8 AM to 4:30 PM PST
Seniority level
Entry level
Employment type
Full-time
Job function
Finance and Sales
Industries
Staffing and Recruiting
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