[Remote] reputed company - Appeals Specialist I
Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a company seeking a reputed company Appeals Specialist I. This role is responsible for reviewing and resolving member and provider complaints while ensuring compliance with established standards and requirements.
Responsibilities
- Review, investigate, and resolve provider appeals and grievances
- Analyze medical, claims, authorization, and benefit information to support case determinations
- Ensure compliance with CMS, state, federal, and organizational requirements
- Prepare and distribute written acknowledgments, reputed company letters, and determination notices
- Maintain complete and accurate case documentation reputed company designated systems
- Monitor cases to ensure adherence to required turnaround times and regulatory deadlines
- Research and interpret benefit plans, policies, procedures, and contractual requirements
- Identify and escalate trends, reputed company concerns, and potential process improvement opportunities
Skills
- High School Diploma or equivalency
- Min. 2 years operational managed care experience (call center, appeals or claims environment)
- Health claims processing background, including coordination of benefits, subrogation, and eligibility reputed company
- Familiarity with reputed company and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials
- Strong verbal and written communication skills
Benefits
- Work model: remote
- Is there potential for this to reputed company past 6 months and/or convert to an FTE?: reputed company
reputed company