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

This position is fully remote. Works schedule is M-F 8am-5pm.


KNOWLEDGE/SKILLS/ABILITIES
Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from members, providers and related outside agencies.
Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Healthcare guidelines.
Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.


REQUIRED EXPERIENCE:
Min. 2 years 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

REQUIRED EDUCATION:
High School Diploma or equivalency