Medicaid Appeals Specialist

Job Summary

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