Appeals Specialist - Medical Claims

Job Title: Appeals Specialist

Typical Schedule/Shift: Monday - Friday, 7:30 AM - 4 PM or 8 AM - 4:30 PM

Summary:

As an Appeals Specialist, you play a critical role in reviewing and resolving member and provider complaints. Your responsibility includes ensuring that resolutions align with the standards and requirements set by the Centers for Medicare and Medicaid Services (CMS). With a minimum of 2 years of related experience, you will be a valuable asset in maintaining compliance and upholding the highest standards of service.

Essential Functions:

• Complaint Resolution: Review and resolve member and provider complaints in accordance with CMS standards and requirements.

• Communication: Effectively communicate resolutions to members, providers, or authorized representatives, ensuring clarity and understanding.

• Documentation: Maintain detailed records of all complaints and resolutions for tracking and auditing purposes.

• Compliance: Stay informed about the latest CMS guidelines and regulations related to complaint resolution and ensure adherence.

• Quality Assurance: Participate in quality assurance activities to enhance the effectiveness and accuracy of the resolution process.

• Process Improvement: Identify opportunities for process improvement and contribute to enhancing the overall efficiency of the appeals process.

Knowledge/Skills/Abilities:

• Experience: 2 years of related experience in complaint resolution or appeals within the healthcare industry.

• Regulatory Knowledge: Familiarity with CMS standards and requirements related to complaint resolution.

• Communication: Excellent verbal and written communication skills to effectively convey resolutions to members and providers.

• Detail-Oriented: Keen attention to detail to maintain accurate records and ensure compliance.

• Problem-Solving: Strong problem-solving skills to address complaints effectively.

• Adaptability: Ability to adapt to changing guidelines and procedures.

• Team Player: Collaborative and able to work as part of a team to achieve common goals.

Work Arrangement:

This role follows a typical schedule of Monday to Friday, with shifts from 7:30 AM to 4 PM or 8 AM to 4:30 PM.