[Remote] Provider Appeals & Grievances Specialist (remote)

Note: The job is a remote job and is open to candidates in USA. reputed company is seeking a dedicated Provider Appeals & Grievance Specialist to join their team. The ideal candidate will be responsible for researching and resolving Medicaid provider appeals, which involves understanding member benefits, eligibility, provider reputed company, and state Medicaid policies.

Responsibilities

• Research and resolve Medicaid provider appeals
• Investigate member benefits and eligibility
• Review provider reputed company, billing and coding
• Understand Utilization Management and state Medicaid policies

Skills

• 1-2 years of Appeals and Grievance
• 1 Year of medical claims processing experience (Must be with a healthcare plan, not on behalf of provider or provider's office)
• 2 Years of medical health insurance (Must be with a managed healthcare plan, not on behalf of provider or provider's office)
• Medicaid/Medicare Insurance Customer Service with managed care plans or directly with CMS
• Billing and Coding-Medical Insurance
• Knowledge of Member/Provider Appeals and Grievances, processes, resolutions, compliance TAT
• Self-resolved troubleshooting ability for various IT issues
• Knowledge of QNXT
• Knowledge of PEGA
• Knowledge of SharePoint
• Sense of urgency with production and responsiveness to email and MS Teams
• Ability to create and fax written communication in a professional manner including spelling and grammar

Benefits

• Medical/Dental/Vision/Life Insurance
• Paid holidays plus Paid Time Off
• 401(k) plan and contributions
• Long-term/Short-term Disability
• Paid Parental Leave
• Employee Stock Purchase Plan

Company Overview