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Medicaid Appeals Specialist

3 months ago

California, United States Themesoft Inc. Full time

Job Title: Provider

Location: Remote

Duration: Contract

Job Overview:

The ideal candidate will possess:

  • 1-2 years of experience in Appeals and Grievance processes.
  • At least 1 year of experience in medical claims processing within a healthcare plan.
  • Experience in Medicaid insurance customer service or claims processing.
  • Proficiency in Microsoft programs, demonstrating navigation skills in a fast-paced, production-oriented environment.
  • A strong commitment to attendance adherence, especially during training.

Role Responsibilities:

The selected individual will be tasked with:

  • Researching and resolving Medicaid provider appeals, which includes understanding member benefits, eligibility, provider contracts, billing and coding, Utilization Management, and state Medicaid regulations.

Additional Qualifications:

  • Experience in Medicaid/Medicare Insurance Customer Service with managed care plans or directly with CMS.
  • Knowledge of Billing and Coding in Medical Insurance.
  • Excellent written and verbal communication skills.
  • Ability to troubleshoot various IT issues independently.
  • Familiarity with Member/Provider Appeals and Grievances processes, including compliance and turnaround time.
  • A strong sense of urgency in production and responsiveness to communication platforms.
  • A commitment to quality in all tasks.
  • Familiarity with QNXT, PEGA, and SharePoint.
  • Ability to produce professional written communication with attention to spelling and grammar.