Medicaid Appeals Specialist

A company is looking for a Specialist, Appeals & Grievances with Medicaid experience.

Key Responsibilities

Research and resolve appeals, grievances, and complaints from members and providers in compliance with regulatory timelines

Review medical records and claims to determine outcomes and ensure timely responses according to guidelines

Prepare appeal summaries and correspondence, documenting findings and trends as necessary

Required Qualifications

High School Diploma or equivalency

Minimum of 2 years of operational managed care experience in a call center, appeals, or claims environment

Experience with health claims processing, including coordination of benefits and eligibility criteria

Familiarity with Medicaid and Medicare claims denials and appeals processing