Claims Appeals Specialist
Claims Appeals Specialist
Employer Active
Job Alert
You will be updated with latest job alerts via email
Share
Job Alert
You will be updated with latest job alerts via email
Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
Appeals Specialist I Managed Care Organization
Location: 100 Remote Candidates must reside in one of the following states: AZ FL GA ID IA KY MI NE NM NY OH TX UT WA or WI
Pay: $22/hour
Assignment Type: TemptoPerm
Work Schedule: Monday Friday Standard Business Hours (Local Time)
Benefits: Medical dental vision and 401(k) with 50 employer contribution towards premiums
About the Organization
Join a missiondriven managed care organization serving Medicaid and Medicare members nationwide. This organization is known for delivering highquality communitybased healthcare solutions and advocating for underserved populations. As part of a collaborative and compliancefocused team youll contribute directly to the resolution of member and provider appeals while ensuring adherence to regulatory standards.
Position Overview
The Appeals Specialist I is responsible for investigating and resolving member and provider complaints appeals disputes and grievances in compliance with state federal and internal regulations. This is a 100 remote position ideal for candidates with a background in managed care claims processing Medicare/Medicaid policy and strong communication skills.
Key Responsibilities
Conduct comprehensive research and resolution of appeals grievances disputes and complaints from members providers or external agencies
Utilize internal systems to research claims and determine appropriate outcomes in accordance with regulatory requirements and timelines
Request and review medical records clinical notes and billing details as needed to support appeals processing
Apply benefits language and service coverage guidelines in evaluating each case
Draft appeal summaries regulatory correspondence and resolution letters accurately and concisely
Communicate decisions and case updates to members and providers via phone and written communication
Maintain production targets and accuracy standards set by the department
Identify trends and recurring issues; provide documentation upon request
Investigate root causes of payment errors by reviewing claims processing rules fee schedules and provider contracts
Respond to provider reconsideration requests and prepare written resolutions for claim adjustments
Required Qualifications
Education:
High School Diploma or GED required
Experience:
Minimum 2 years of operational experience in managed care (appeals call center or claimsrelated roles)
Knowledge of Medicaid and Medicare regulatory guidelines for denials and appeals
Experience with health claims processing including eligibility subrogation and coordination of benefits
Strong written and verbal communication skills with attention to accuracy and detail
Required Experience:
Unclear Seniority
Employment Type
Hourly
