Medicare Claims Appeals Clerk (Full Remote) - Two Chicks With A Side Hustle

Job Summary

The Medicare Claims Appeals and Grievances Specialist is responsible for reviewing and resolving member and provider complaints, and communicating resolutions to members and providers (or authorized representatives) in accordance with standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).

Knowledge/Skills/Abilities

Comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from members, providers, and related outside agencies to ensure internal and/or regulatory timelines are met.
Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.

Request and review medical records, notes, and/or detailed bills as appropriate; formulate conclusions per protocol and collaborate with other business partners to determine response; ensure timeliness and appropriateness of responses per state and federal guidelines.
Meet production standards set by the department.
Apply contract language, benefits, and review covered services.

Contact 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 and/or 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 requests from outside agencies.

Job Qualifications

Required Education:

High School Diploma or equivalency

Required Experience:

Minimum 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.

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