Medical Appeals Specialist I

AltaStaff is a staffing agency currently looking for an Appeals Specialist for one of our Managed Care partners.

This role is fully remote but candidates must work PST hours

Pay: $21.00 - $23.00 hourly

Schedule: Monday - Friday; 8:00am - 5:00pm PST and rotating weekends

Position Purpose: Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. This role will be primarily processing A&G cases.

Job Responsibilities:

• Responsible for the comprehensive research and resolution of the appeals, disputes, grievances, and/or complaints from members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.
• Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Healthcare guidelines.
• Responsible for meeting production standards set by the department.
• Apply contract language, benefits, and review of covered services
• Responsible for contacting the member/provider through written and verbal communication.
• Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
• Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.

Job Qualifications:

• High School Diploma/GED Required
• Min. 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

AltaStaff is an Equal Employment Opportunity Employer. We provide equal employment opportunities to all qualified applicants for employment without regard to age, race, color, creed, religion, sex, marital status, national origin, ancestry, citizenship, disability, veteran status, sexual orientation, or any other protected status, in accordance with applicable federal, state, and local laws.

INDHP