Appeals Specialist

2 months ago


New York, United States OMG Technology Full time

**Appeals Specialist - I (Remote - EST or PST)**

The schedule will be **Monday to Friday 8 am-5 pm** local time**.**

**Position Summary**:
Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and providers (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid
- **This is a 6-month contract with the possibility of extension**.

**Position Responsibilities**:

- Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina 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 to assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines. Responsible for meeting production standards set by the department.
- 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.
- Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
- Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies.

**Required Skills/Experience/Education**:

- At least 2+ years of **operational managed care experience**(call center, appeals, or claims environment).
- Experience with **health claims processing background**, including **coordination of benefits, subrogation,**and **eligibility criteria.**:

- Familiarity with **Medicaid and Medicare claims denials and appeals processing.**:

- Knowledge of **regulatory guidelines for appeals and denials**.
- Strong verbal and written communication skills.
- High School Diploma or equivalency.
- **Equipment Provided**:This role will require 2 Monitors, a computer/laptop, a mouse, a keyboard, and a headset.

**Other job specifications**:

- **_Employment Type: _**Contract to Hire (CTH), **W2 only. NO C2C.**:

- **_Contracting Period_**_:_6-month contracting opportunity with the possibility of extension.
- **_Job Location: _**Remote in EST/CST
- **_The Schedule: _**Will be Monday to Friday 8 am-5 pm local time.
- **_Contract Rate/Salary: _**$21/hr**. on W2.
- **_Interview Process: _**Phone/WebEx.



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