Employer Industry: Healthcare Services

Why consider this job opportunity:
- Opportunity for career advancement within the organization
- Competitive benefits and compensation package
- Engage in meaningful work by resolving member and provider complaints
- Supportive work environment that values compliance and quality
- Chance to develop skills in appeals, claims processing, and member relations

What to Expect (Job Responsibilities):
- Conduct comprehensive research and resolution of appeals, disputes, grievances, and complaints from members and providers
- Review medical records and detailed bills to formulate conclusions per protocol
- Communicate findings and resolutions to members and providers through written and verbal correspondence
- Prepare appeal summaries and document findings, including trend analysis when requested
- Resolve incoming provider reconsideration requests related to claims payment adjustments

What is Required (Qualifications):
- High School Diploma or equivalency
- Minimum of 2 years of operational managed care experience in a call center, appeals, or claims environment
- Background in health claims processing, including coordination of benefits and eligibility criteria
- Familiarity with Medicaid and Medicare claims denials and appeals processing
- Strong verbal and written communication skills

How to Stand Out (Preferred Qualifications):
- Experience in regulatory guidelines for appeals and denials
- Knowledge of provider contracts and fee schedules

#HealthcareServices #ClaimsProcessing #MemberRelations #CareerOpportunity #EqualOpportunityEmployer

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