Claims and Appeals Specialist

Empowering Wellness, Transforming Lives

Optima Medical Management Group is dedicated to enhancing the quality of life by promoting wellness. At Optima MMG and all of its divisions: Serene Health, Community Support, and American TrueCare, our mission is to provide comprehensive support and care that not only addresses immediate concerns but also fosters long-term well-being.

As pioneers in the field, we aspire to lead in member care outcomes and set new standards for excellence and innovation. We are committed to empowering our members to achieve self-sufficiency in health, creating a ripple effect that strengthens families and communities.

Our work culture at Optima MMG is built on pride, passion, and a collective commitment to making a positive difference in people's lives. Our team members are dedicated problem-solvers who bring their unique skills and perspectives to the table. We believe that by fostering a collaborative and supportive environment, we can unlock the full potential of our team and, in turn, provide the best possible care to our members.

A career at Optima MMG is an opportunity to be part of a dynamic and forward-thinking organization. We encourage continuous learning and professional growth, providing our employees with access to industry experts, cutting-edge technologies, and a supportive community that values each individual's contributions. Join us on this journey to not only advance your career but to be a driving force in transforming lives and communities through passionate and fulfilling work

Job Summary:

We are seeking a detail-oriented and experienced Claims and Appeals Specialist to join our team. This role is essential to ensuring accurate claims submission, timely resolution of denials, and adherence to payer and regulatory guidelines. The ideal candidate will be responsible for reviewing and submitting claims, identifying and resolving issues related to denials, and following up with insurance carriers to ensure proper reimbursement.

Duties/Responsibilities:

• Review remittance advice to identify denials, partial payments, or claim issues.
• Once denials are identified and researched, submit accurate resolution response to appropriate payers.
• Analyze claim rejections and denials and initiate appeals as needed.
• Maintain up-to-date knowledge of payer policies and compliance requirements.
• Work closely with the billing team and ECM/ CS teams to obtain necessary documentation.
• Communicate with health plans and clearing houses to resolve discrepancies.
• Track appeals and follow up until a resolution is achieved.
• Document all actions and correspondence in the system.
• Provide updates to internal teams regarding claim statuses and trends.
• Perform other duties as assigned.

Education and Experience:

• High school diploma or GED required; BA degree preferred.
• 1-2 years of claims processing or medical billing experience.

Required Skills/Abilities:

• Proficient in Excel, PivotTables, SharePoint, and Health Plan portals.
• Experience with EHRs and clearinghouse platforms.
• Strong analytical, organizational, and communication skills.
• Ability to work independently and meet deadlines.

Physical Requirements:

• Prolonged periods sitting at a desk and working on a computer.
• Must be able to lift up to 10 pounds at times.

Benefits

Our full-time employees are eligible for the following benefits enrollment after 60 days of employment:

Medical, Dental, & Vision Benefits: We have various insurance options for you and your family.

Short & Long-Term Disability Benefits: Protection when you need it most.

Voluntary Accident, Voluntary Critical Illness, and Voluntary Hospital Indemnity Plans: Added security for you and your loved ones.

Flexible Spending Accounts: Manage your finances with flexibility.

Employee Assistance Program (EAP): Support when life throws challenges your way.

401(K): Building your financial future with us. Effective after 1 year of employment.

Paid Vacation and Sick Leave: Flexibility for the planned and unplanned.

Paid Holidays: Quality time to enjoy celebrations.

Employee Referral Program: Share the opportunities and reap the rewards.

Company Discount Program: Enjoy savings on everyday expenses and memberships.

Equal Employment Opportunity

Optima Medical Management Group and its divisions are an Equal Opportunity Employer. Optima MMG is committed to providing employment opportunities for all qualified candidates without discrimination on the basis of race, religion, sex, sexual orientation, gender identity, age, national origin, citizenship, disability, marital status, veteran status, or any other characteristic protected by federal, state or local laws. Optima MMG is committed to providing reasonable accommodation for individuals with disabilities.

Pre-Employment

Optima Medical Management Group is a drug-free workplace. Employment is contingent upon a successful pre-employment drug screening and background check.