Remote Appeals and Grievances Specialist

Job is Expired

Location: Texas

Compensation: To Be Discussed

Staff Reviewed: Fri, Jul 02, 2021

Job Category: Healthcare

Remote Level: 100% Remote

Weekly Hours: Full Time

Employer Type: Employer

Education Level: Some College, Bachelors

Job Summary

A healthcare company is in need of a Remote Appeals and Grievances Specialist.

Core Responsibilities of this position include:

  • Researching issues utilizing systems and clinical assessment skills, knowledge and approved “Decision Support Tools” in the decision making process regarding health care services and care provided to members
  • Requesting and reviewing medical records, notes, and/or detailed bills as appropriate; evaluates for medical necessity and appropriate levels of care; formulates conclusions per protocol and collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines
  • Preparing appeal summaries, correspondence and documents information for tracking/trending data; assists in the preparation of narratives, graphs, flowcharts, etc. for presentations and audits

Skills and Requirements Include:

  • High School Diploma or GED
  • Min. 1 year Claims experience and 1 year managed care experience
  • Claims processing background, including coordination of benefits, subrogation, and SB1264
  • Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials
  • Excellent communication skills

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