Pay Range $19/hr-$21/hr

About the Role:

• We are looking for a Remote Member and Provider Complaint Resolution Specialist to join our team.
• The ideal candidate must reside in one of the preferred 15 states and will be responsible for reviewing and resolving member and provider complaints in accordance with established standards.

Responsibilities: -

• Research member complaints, update system with research findings, and resolve complaints within specified timeframe
• Conduct comprehensive research and resolution of appeals, disputes, grievances, and complaints from client members, providers, and outside agencies
• Review 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 root cause of 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
• Knowledge of regulatory guidelines for appeals and denials
• Strong verbal and written communication skills If you meet the qualifications and are looking for a remote opportunity to utilize your skills in resolving member and provider complaints, we encourage you to apply for this position.

Benefits

The Company offers the following benefits for this position, subject to applicable eligibility requirements: medical insurance, dental insurance, vision insurance, 401(k) retirement plan, life insurance, long-term disability insurance, short-term disability insurance, paid parking/public transportation, paid time off, paid sick and safe time, hours of paid vacation time, weeks of paid parental leave, and paid holidays annually – as applicable.