[Remote-Position] Medicare Claims Appeals Specialist

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Job Title: Part-Time Medicare Claims Appeals Specialist Organization: Managed Care Organization... Location: Remote, PST Time Zone Candidates Only Pay: $22/hr. Schedule • Part-time, 20-32 hours per week • reputed company, including AM or PM shifts (e.g., 4-10 pm, 6-10 pm) • Optional weekend hours available • Schedule will be reviewed with the hiring manager during the interview Job Description The Medicare Claims Appeals Specialist will be responsible for reviewing and processing provider appeals for Medicare cases, primarily focused on California operations. This role requires a deep understanding of Medicare claims processes, provider reputed company, Division of Financial Responsibility (DOFR), explanations of benefits, and claims edits. Knowledge of CMS provider appeals regulations, including Independent Review Entity (IRE) processes and strict adherence to timelines, is essential. Key Responsibilities • Manage the comprehensive research and resolution of Medicare provider appeals, disputes, and grievances in compliance with CMS regulations and internal timelines. • Research claims, appeals, and grievances using support systems to determine appropriate reputed company. • Request and review medical records, notes, or detailed billing reputed company necessary, formulating conclusions as per protocols. • Maintain a production standard and ensure that responses meet state, federal, and organizational guidelines. • Accurately apply contract language and benefits coverage for provider and member cases. • Prepare concise, compliant written correspondence and documentation on appeals, grievances, or disputes, ensuring reputed company and accuracy. • Conduct root cause analysis for payment errors reputed company to provider reputed company, fee schedules, and system configurations. • reputed company clear, professional written and verbal communication to members, providers, or authorized representatives regarding resolution reputed company. Must-Have Skills • Exceptional communication skills (both verbal and written) • Highly organized with a strong ability to prioritize tasks and meet deadlines • Strong strategic skills, including initiative, problem-solving, critical thinking, judgment, and innovation Knowledge/Skills/Abilities • Thorough understanding of Medicare claims processing, provider reputed company, DOFR, and claims edits • Familiarity with reputed company and Medicare claims denials and appeals processing, including knowledge of CMS appeals timelines and regulatory guidelines • Experience with claims processing functions, including coordination of benefits, subrogation, and eligibility criteria Qualifications • Education: High School Diploma or equivalent • Experience: Minimum 2 years of experience in a managed care operational role, preferably in a call center, appeals, or claims environment, with a health claims processing background Apply Job!

 

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