Texas Appeals Specialist

Job Summary

Facilitating the resolution of appeals and grievances, the full-time Texas Appeals Specialist will manage member and provider complaints, ensuring compliance with CMS standards while working in a dynamic healthcare environment.

Key responsibilities

• Research and resolve appeals, disputes, and grievances from members and providers, adhering to internal and regulatory timelines
• Request and review medical records and claims documentation to formulate appropriate responses and conclusions
• Prepare appeal summaries and correspondence, documenting findings and trends in accordance with regulatory requirements

Required qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment
• Experience with Medicaid and Medicare claims denials and appeals processing
• Health claims processing experience, including coordination of benefits and eligibility criteria
• Strong organizational and time management skills to manage multiple tasks effectively
• Proficiency in Microsoft Office suite and applicable software programs