Specialist, Appeals & Grievances - Remote

About Our Client:The organization operates within the managed care industry, focusing on providing healthcare services under Medicaid, Medicare, Marketplace, and other government-sponsored programs. It addresses challenges related to claims processing, appeals, and grievances to ensure compliance with regulatory requirements and timely resolution for members and providers. About the Opportunity:The SPECIALIST, APPEALS & GRIEVANCES role supports claims activities by researching and resolving appeals, disputes, grievances, and complaints from members and providers. This position ensures responses meet regulatory and internal standards, contributing to accurate claims processing and member satisfaction. Responsibilities:Facilitate research and resolution of appeals, disputes, grievances, and complaints to meet internal and regulatory timelines.Research claims appeals and grievances using support systems to determine outcomes.Request and review medical records, notes, and detailed bills; formulate conclusions according to protocol and business partner input.Meet departmental claims production standards.Apply contract language, benefits, and service reviews to claims processing.Communicate with members and providers via written and verbal methods.Prepare appeal summaries, correspondence, and document findings, including trend information.Compose correspondence and appeals information in compliance with regulatory requirements.Research claims processing guidelines, provider contracts, fee schedules, and system configurations to identify payment error causes.Respond in writing to provider reconsideration requests related to claims payment and adjustments. Requirements:Minimum 2 years of managed care experience in call center, appeals, or claims environment, or equivalent education and experience.Experience with health claims processing including coordination of benefits, subrogation, and eligibility.Knowledge of Medicaid and Medicare claims denials, appeals processing, and regulatory guidelines.Customer service experience.Strong organizational and time management skills to handle multiple projects and meet deadlines.Effective verbal and written communication skills.Proficiency with Microsoft Office and applicable software. Preferred Qualifications:Experience with customer or provider interactions in managed care organizations or medical office/hospital settings.Completion of a healthcare-related vocational program such as certified coder, billing, or medical assistant. Pay Range and Compensation Package:The pay range and compensation package for this role will be determined based on the candidate's experience, skills, and other relevant factors. Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin. Note:RemoteHunter is a recruitment partner of this role. Please note that all employment decisions, including candidate assessment, interviews, hiring, compensation, and employment terms, are made exclusively by the hiring employer.