About the Role:

• We are looking to fill 5 remote positions for individuals living in one of the preferred 15 states.
• The role involves researching and resolving member complaints, updating systems, and resolving complaints within specified timeframes. The schedule will be Monday to Friday, 8am to 4:30pm.

Responsibilities: -

• Conduct comprehensive research and resolution of appeals, disputes, grievances, and complaints from client members, providers, and outside agencies.
• Research claims appeals and grievances using support systems to determine outcomes. 
• Request and review medical records, notes, and bills to formulate conclusions and determine responses.
• Meet production standards set by the department.
• Contact members/providers through written and verbal communication.
• Prepare appeal summaries, correspondence, and document findings accurately.
• Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine payment errors. 
• Resolve and prepare written responses to provider reconsideration requests and requests for claim adjustments.

Education Qualification: -

• High School Diploma or equivalency

Required Skills: -

• Minimum 2 years of operational managed care experience (call center, appeals, or claims environment).
• Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.
• Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines.
• Strong verbal and written communication skills.