Appeals Specialist - New York, United States - OMG Technology

OMG Technology

Verified Company

New York, United States

6 days ago

Posted by:

Mark Lane

beBee recruiter

Description

Appeals Specialist - I (Remote - EST or PST)
The schedule will be
Monday to Friday 8 am-5 pm local time
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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
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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.
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.

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Equipment Provided:

This role will require 2 Monitors, a computer/laptop, a mouse, a keyboard, and a headset.

Other job specifications:

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Employment Type:
_Contract to Hire (CTH),
W2 only. NO C2C
:

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_Contracting Period__:_6-month contracting opportunity with the possibility of extension.
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Job Location:
_Remote in EST/CST
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The Schedule:
_Will be Monday to Friday 8 am-5 pm local time.
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_Contract Rate/Salary: _$21/hr**. on W2.

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Interview Process:
_Phone/WebEx.