Provider (Medicare Claim) Specialist

Responsible for reviewing and resolving provider disputes and communicating resolution to provider in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Job Responsibilities:
Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from 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; assures timeliness and appropriateness of responses per state, federal and Healthcare guidelines.
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
TOP SKILLS:
1.Provider Appeals and Grievance on the insurance side of the business

2.Claims review/processing/billing & coding experience

3.Healthcare Insurance Customer Service experience

Additional Information:
Monday-Friday 8 am 4:30 pm EST

The team is supported by multiple specialists who assist with onboarding and questions.

There are 2 team huddles a week for announcements and check ins as well as team building activities 2 times a month.

Training is 4 to 6 weeks in which 100% attendance is REQUIRED.

The associate will then have a ramp up period of 8 weeks to meet their expected metrics.

3 Years of Experience