Appeals Specialist

Job Summary

A company is looking for a Specialist in Appeals & Grievances.

Key Responsibilities:

• Review and resolve member and provider complaints in accordance with established standards
• Research and resolve appeals, disputes, and grievances from members and providers
• Contact members/providers, prepare appeal summaries, and compose correspondence accurately

Required Qualifications:

• High School Diploma or equivalency
• Minimum 2 years operational managed care experience
• Health claims processing background, including Medicaid and Medicare knowledge
• Familiarity with appeals and denials processing and regulatory guidelines
• Experience in claims processing guidelines and provider contracts