Appeals Specialist I

Job Description: position is for an Appeals and Grievances Specialist
8am-430pm in whichever timezone candidate resides in
Candidates need to be located in 1 of the following 15 states: Client, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI
potential to convert to an FTE
weekly OT will vary

Job Description:
Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Client members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.
Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and *** guidelines.
Responsible for meeting production standards set by the department.
Apply contract language, benefits, and review of covered services
Responsible for contacting the member/provider through written and verbal communication.
Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies

Must Have Skills:
Proficient in Microsoft Office Suite (Excel, Word, etc.) and other relevant software tools.
Min. 2 years 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 for appeals and denials.
Strong verbal and written communication skills

Day to Day Responsibilities:
1. Screening Clinical Appeals and Reviewing Non Clinical Appeals
o Utilize claims processing systems to reprice claims and ensure data integrity.
o Reprice medical claims based on contracted rates, including Medicare, Medicaid, PPO, HMO, and other networks.
o Apply the appropriate pricing, contractual rates, and reimbursement methodologies.
o Ensure that all pricing changes are well-documented and communicated clearly.

2. Claims Review & Analysis:
o Review medical claims for accuracy in accordance with insurance policy guidelines.
o Ensure that claims are processed correctly in terms of eligibility, coverage, and benefits.

3. Communication & Collaboration:
o Collaborate with other departments (e.g., customer service, claims processing) to resolve complex claim processing issues.

4. Problem Solving:
o Investigate and resolve claims-related issues such as incorrect pricing, discrepancies between billed charges and contracted rates, and payment errors.
o Provide support in resolving claim disputes.
Required Years of Experience: 2+ years of experience in medical claims, claims processing, or insurance repricing.

Required Licensure / Education:
High school diploma or equivalent (Associate's or Bachelor's degree in healthcare or business preferred).
Knowledge of medical billing codes (CPT, ICD-10, HCPCS), insurance terminology, and claims processing systems.
Knowledge of reimbursement methodologies and healthcare contracts.
Familiarity with different types of insurance plans (PPO, HMO, Medicare, Medicaid, etc.).
Experience with claims management systems (e.g., Facets, QNXT, or similar).