Medicare Claims Appeals Specialist

Job Summary

A company is looking for a Medicare Claims Appeals and Grievances Specialist to review and resolve member and provider complaints.

Key Responsibilities

• Research and resolve appeals, disputes, grievances, and complaints from members and providers
• Request and review medical records and formulate conclusions in accordance with regulatory guidelines
• Prepare appeal summaries and written responses to provider reconsideration requests related to claims payment

Required Qualifications

• High School Diploma or equivalency
• Minimum 2 years of operational managed care experience
• Health claims processing background, including coordination of benefits and eligibility criteria
• Familiarity with Medicaid and Medicare claims denials and appeals processing