Appeals & Grievances Processor
Job Description
We are seeking a dedicated and detail-oriented Appeals & Grievances Processor with a strong background in the US healthcare payor sector. This role involves working as part of a team to resolve complex member and provider issues related to appeals and grievances, ensuring compliance with Medicare, Medicaid, and health plan standards. Minimum Qualifications:
• 2+ years of experience in the US healthcare payor sector.
• 1+ year of experience in processing appeals and grievances.
• Strong understanding of denial management and claims adjudication.
• Experience with Medicare and Medicaid from the payor side. Responsibilities:
• Analyze and resolve member and provider appeals, grievances, and disputes in compliance with regulatory requirements.
• Prepare and organize case research, notes, and documents.
• Communicate effectively with members and providers, both verbally and in writing.
• Obtain and review medical records, notes, and bills to apply contract language and benefits.
• Conduct research and analysis to recommend appropriate actions for management review.
• Determine the root cause of payment errors and resolve them using support systems.
• Compose concise and accurate correspondence regarding appeals and grievances.
• Collaborate with provider and member services to address balance bill issues and complaints.
• Ensure timely and appropriate responses per state, federal, and health plan guidelines.
• Meet departmental production standards.
• Prepare appeal summaries and document findings, including trend information as needed. Preferred Knowledge/Skills:
• Strong verbal and written communication skills, including letter writing.
• Proficiency in Microsoft Word, Excel, and PowerPoint.
• Excellent organizational, interpersonal, and time management skills.
• Attention to detail and ability to prioritize tasks and work under firm deadlines.
• Enthusiastic team player with the ability to interact successfully with members, medical professionals, and government representatives.
• Familiarity with the Pega computer system is a plus. Certifications:
• No specific certifications required. Additional Information:
• This position requires 100% work from the office.
• The role operates during night shifts to accommodate client and organizational needs.
