Claims Appeals and Grievances Specialist
Job Posting for Claims Appeals and Grievances Specialist at Morgan Stephens
Job Posting: Claims Appeals and Grievances Specialist
Job Summary
The Claims Appeals and Grievances Specialist is responsible for reviewing and resolving member and provider complaints and communicating resolutions to members and providers (or their authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).
Knowledge/Skills/Abilities
Job Summary
The Claims Appeals and Grievances Specialist is responsible for reviewing and resolving member and provider complaints and communicating resolutions to members and providers (or their authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).
Knowledge/Skills/Abilities
- Conduct comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from members, providers, and related outside agencies to ensure compliance with internal and/or regulatory timelines.
- Utilize support systems to research claims appeals and grievances, determining outcomes accordingly.
- Request and review medical records, notes, and/or detailed bills as appropriate; formulate conclusions per protocol and collaborate with other business partners to determine responses, ensuring timeliness and appropriateness per state, federal, and guidelines.
- Meet production standards set by the department.
- Apply contract language, benefits, and review of covered services.
- Communicate with members/providers through written and verbal communication.
- Prepare appeal summaries, correspondence, and document findings, including information on trends if requested.
- Compose all correspondence and appeal/dispute/grievances information concisely and accurately, in accordance with regulatory requirements.
- Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine the root cause of payment errors.
- Resolve and prepare written responses to incoming provider reconsideration requests relating to claims payment and requests for claim adjustments, or to requests from outside agencies.
- High School Diploma or equivalency
- Minimum of 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.
Salary : $20
Medicare Claims Appeals Clerk (Full Remote)
Morgan Stephens -
Phoenix, AZ
Claims Specialist
Acro Service Corp -
Phoenix, AZ
Deputy Clerk II
Arizona Court of Appeals -
Phoenix, AZ
Estimate Salary for Claims Appeals and Grievances Specialist in Phoenix, AZ
$23.01 (Medium)
$20.41 (25th)
$25.61 (75th)
For Employer
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