Specialist, Appeals & Grievances - Remote

Job Description

• Full-time remote Specialist, Appeals & Grievances role supporting managed-care claims, member/provider complaints, appeals, disputes, grievances, and reconsideration requests.
• Research claims, medical records, bills, contracts, benefits, fee schedules, provider agreements, and system configurations to determine outcomes and root causes of payment errors.
• Prepare accurate appeal summaries, regulatory correspondence, written determinations, and responses while meeting state, federal, CMS, Molina, and departmental production/timeliness standards.
• Requires at least 2 years of managed care call center, appeals, and/or claims experience; health claims processing knowledge including COB, subrogation, eligibility, and Medicaid/Medicare denials and appeals.
• Requires customer service, strong organization/time management, effective written/verbal communication, and Microsoft Office proficiency; preferred background includes government-sponsored managed care, medical office/hospital work, or a healthcare vocational program.