Appeals Specialist with Operational Managed Care experience (Remote - EST or PST)

Appeals Specialist with Operational Managed Care experience (Remote - EST or PST)

We are looking to hire a candidate with the experience and skill sets mentioned below for one of our major clients within the Health Insurance industry. This is a 6-month contract opportunity.

*Prefer candidates in EST or CST

The schedule will be Monday to Friday 8 am-5 pm local time.

Position Summary:

Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and providers (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

*This is a 6-month contract with the possibility of extension.

Position Responsibilities:

• Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.
• Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response to assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines. Responsible for meeting production standards set by the department.
• Apply contract language, benefits, and review of covered services.
• Responsible for contacting the member/provider through written and verbal communication.
• Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested. 
• Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
• Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
• Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies.

Required Skills/Experience/Education:

• At least 2+ years of operational managed care experience(call center, appeals, or claims environment).
• Experience with health claims processing background, including coordination of benefits, subrogation,and eligibility criteria.
• Familiarity with Medicaid and Medicare claims denials and appeals processing.
• Knowledge of regulatory guidelines for appeals and denials.
• Strong verbal and written communication skills.
• High School Diploma or equivalency.
• Equipment Provided:This role will require 2 Monitors, a computer/laptop, a mouse, a keyboard, and a headset.

Other job specifications:

• Employment Type: Contract to Hire (CTH), W2 only. NO C2C.
• Contracting Period:6-month contracting opportunity with the possibility of extension.
• Job Location: Remote in EST/CST
• The Schedule: Will be Monday to Friday 8 am-5 pm local time.
• Contract Rate/Salary: $21/hr. on W2.
• Interview Process: Phone/WebEx.