Specialist, Appeals & Grievances

Job Description

Provides support for claims activities including reviewing and resolving Provider No Surprises Act cases in accordance with the standards and requirements of Centers for Medicare and Medicaid Services (CMS).

Essential Job Duties

• Responsible for the comprehensive research and resolution of Provider No Surprises Act cases to ensure that internal and / or regulatory timelines are measured correctly.
• Researches claims using support systems to determine Provider No Surprises Act cases outcomes.
• Requests and reviews medical records, notes, and / or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response.
• Meets claims production standards set by the department.
• Applies contract language, benefits and review of covered services to claims review process.
• Contacts providers as needed via written and verbal communications.
• Prepares Provider No Surprises Act correspondence, and documents findings accordingly (includes information on trends as requested).
• Composes all correspondence, and Provider No Surprises Act information concisely and accurately in accordance with regulatory requirements.
• Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.

Required Qualifications

At least 2 years of managed care experience in a call center, appeals, and / or claims environment, or equivalent combination of relevant education and experience. Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. Customer service experience. Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. Effective verbal and written communication skills. Microsoft Office suite / applicable software program(s) proficiency.

Preferred Qualifications

Customer / provider experience in a managed care organization (Medicaid, Medicare, Marketplace and / or other government-sponsored program), or medical office / hospital setting. Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).