Appeals Specialist
The Judge Group Inc.

Job Info

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Location: Long Beach, CA
Description: Our client is currently seeking a Appeals Specialist! This is a REMOTE position! (Candidate can sit anywhere but must work PST hours.)

Summary: Manages submission, intervention and resolution of appeals, grievances, complaints and/or disputes from members or providers and related outside agencies. Conducts pertinent research, evaluates, responds and completes appeals, grievances, complaints and/or disputes and other inquiries accurately, timely and in accordance with all established regulatory guidelines. Prepares appeal summaries and correspondence and documents information for tracking/trending data.

This job will have the following responsibilities:

• Resolves and prepares written response to incoming member or provider appeals, grievances, complaints and/or disputes.
• Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
• Identifies potential provider problems through a proactive approach in which data is mined and trended to identify and prevent provider problem areas.
• Uses a variety of references to research and prepare healthcare provider information for loading into the health plan system/database; enters provider demographics, contract affiliation, or other data as needed.

Qualifications & Requirements:

• High School diploma or GED equivalent
• 2-3 years experience in a managed care setting; CPT and ICD-9 coding, data entry, and 10-Key experience.
• 2-3 years managed care experience; claims review and processing background including coordination of benefits, subrogation, and eligibility criteria.
• Experience in eligibility/enrollment and benefits, as well as experience with Member and/or Provider Appeals and Grievances and Claims review or Claims Processing (Claims experience over grievances is preferred).

If you or someone you know is both qualified and interested in this position, please send your current resume to Ashley at awine@judge.com!

Contact: awine@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com

This job has expired.