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Appeals Specialist

Phoenix, AZ

Job Title: Healthcare - Appeals Specialist I

Location: Phoenix, AZ 85034

Schedule: Monday to Friday, 8:00 am to 5:00 pm (On-site)

Job Summary: The Healthcare Appeals Specialist I is responsible for reviewing and resolving member and provider complaints and communicating resolutions to members and providers (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Key Responsibilities:

  • Process A&G (Appeals and Grievances) cases, ensuring timely and accurate resolution.
  • Open, receive, and scan mail as part of daily job duties.
  • Conduct comprehensive research and resolution of appeals, disputes, grievances, and complaints from members, providers, and related outside agencies.
  • Utilize support systems to research claims appeals and grievances, determining outcomes and formulating conclusions per protocol and regulatory guidelines.
  • Request and review medical records, notes, and/or detailed bills as appropriate, ensuring timeliness and appropriateness of responses per regulatory guidelines.
  • Meet production standards set by the department.
  • Apply contract language, benefits, and review covered services to determine appropriate responses.
  • Contact members/providers through written and verbal communication.
  • Prepare appeal summaries, correspondence, and document findings accurately and concisely, adhering to regulatory requirements.
  • Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine root causes of payment errors.
  • Resolve and prepare written responses to incoming provider reconsideration requests related to claims payment and requests for claim adjustments or from outside agencies.

Job Qualifications: Required Education:

  • High School Diploma or equivalency

Required Experience:

  • Minimum of 2 years of operational managed care experience (call center, appeals, or claims environment).
  • Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.
  • Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
  • Strong verbal and written communication skills.

This position offers the opportunity for growth and advancement within our organization. If you are a detail-oriented individual with a passion for resolving complex healthcare appeals and grievances, we encourage you to apply.

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