Healthcare Appeals Specialist

4 weeks ago


Indianapolis, Indiana, United States CareSource Full time
Job Summary:

The Grievance & Appeals Specialist II is responsible for reviewing appeals submitted by Medicaid and Medicare providers and all future providers contracted with CareSource. This role requires strong analytical and communication skills to ensure accurate and timely resolution of appeals.


Key Responsibilities:
  • Prepare appeals for clinical review and track their progress
  • Review submitted appeals for validation and identify appropriate claim problems
  • Prepare clinical edit appeals for review by computer research and attend Appeals Committee meetings as needed
  • Maintain spreadsheets of appeals reviewed and document outcomes in Facets
  • Identify system changes and log tickets for resolution
  • Complete claim appeals through adjustments or letters of denial
  • Review appeals for possible fraud and abuse and report to SIU
  • Research and release claim appeals with other health insurance and notify the COB unit
  • Process a variety of appeals, including dental, low difficulty, non-clinical, medically frail, RCP, member, and provider appeals

Requirements:
  • High school diploma or equivalent required; Associates Degree or equivalent years of relevant work experience preferred
  • Minimum of two (2) years of healthcare customer service, claims, compliance, or related experience required
  • Strong technical writing skills and intermediate level skills in Microsoft Word & Excel with Access skills a plus
  • Excellent communication, multitasking, and time management skills
  • Familiarity with the Healthcare field and knowledge of Medicaid

Working Conditions:
General office environment; may be required to sit or stand for extended periods of time

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