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Medicaid Appeals Specialist

3 months ago

California, United States Themesoft Inc. Full time

Job Title: Provider

Location: Remote (8 am to 4:30 PM PST M-F)

Duration: Contract

Job Overview:

The ideal candidate will possess a solid background in Appeals and Grievance processes, with a minimum of 1-2 years of relevant experience. A year of medical claims processing within a healthcare plan is essential, along with proficiency in Medicaid insurance customer service or claims processing.

Key Responsibilities:

  • Conduct thorough research and resolution of Medicaid provider appeals.
  • Navigate member benefits, eligibility, provider contracts, billing and coding, and state Medicaid policies.

Essential Qualifications:

  • Experience in Medicaid/Medicare Insurance Customer Service with managed care plans or directly with CMS.
  • Knowledge of Billing and Coding within Medical Insurance.
  • Strong verbal and written communication skills.
  • Ability to troubleshoot various IT issues independently.
  • Familiarity with Member/Provider Appeals and Grievances processes, resolutions, and compliance turnaround times.
  • Demonstrated sense of urgency in production and responsiveness to communication tools.
  • Quality-driven approach to work.
  • Familiarity with QNXT, PEGA, and SharePoint systems.
  • Proficient in creating and sending professional written communications, ensuring accuracy in spelling and grammar.

Training:

Comprehensive training will be provided, and attendance during this period is mandatory.