Employer Industry: Healthcare Services

Why consider this job opportunity:
- Competitive compensation package with comprehensive benefits
- Opportunity for career advancement and growth within the organization
- Engaging work environment focused on member and provider satisfaction
- Chance to make a positive impact on healthcare quality and accessibility
- Supportive team atmosphere with a focus on collaboration and communication

What to Expect (Job Responsibilities):
- Conduct comprehensive research and resolution of appeals, disputes, grievances, and complaints from members and providers in compliance with regulatory standards
- Review medical records and claims to determine outcomes and formulate appropriate responses
- Prepare and compose appeal summaries and correspondence in accordance with regulatory requirements
- Analyze claims processing guidelines and provider contracts to identify root causes of payment errors
- Communicate effectively with members and providers through written and verbal channels

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

How to Stand Out (Preferred Qualifications):
- Experience with regulatory guidelines for appeals and denials
- Additional certifications related to healthcare claims or managed care

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