Job Description

OVERVIEW:

Our client, a US Fortune 50 organization and a leading provider of Healthcare and Health Insurance services , seeks an accomplished Medical Claims Specialist .

IMPORTANT NOTES: REMOTE / WORK-FROM-HOME RELATED:

• This will be a Remote role.
• Equipment's will be provided.
• MUST have high-speed wired Internet connection. Wi-Fi / Wireless connections are not allowed.
• MUST have a reliable home-office environment.
• Payrate would be $16.85 per hour. The worker must also receive an additional $4.98 per hour payment in lieu of benefits. Total hourly Pay rate would be $21.83 per hour.
• Training Shift Hours: 40 hours per week | 08:00am to 4:30pm (Eastern Time).
• Training will be 5-6 weeks.
• After training, the candidates may choose to flex start time of 6:00 AM to 10:00 AM (Eastern Time).

Client will be considering candidates from below locations only (Please apply accordingly):

• Dearborn, MI
• Wixom, MI
• Cincinnati, OH
• Columbus, OH
• Mason, OH
• Seven Hills, OH
• Hermitage, PA
• Seven Fields, PA
• Knoxville, TN
• Nashville, TN
• Austin, TX
• Grand Prairie, TX
• Houston, TX

Responsibilities:

• This is an entry level position in the NGS Appeals Department that reviews, analyzes and processes non-complex pre-service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (Part A & B) related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
• Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
• Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
• The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements.
• As such, the analyst will strictly follow department guidelines and tools to conduct their reviews.
• Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
• Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
• The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Required Qualifications:

• Must have High School Diploma or GED.
• Must have 4 years’ experience working with Medical Claims, grievances and appeals, Medicare, Part A OR PART B.
• Familiarity with medical terminology, demonstrated business writing proficiency.
• Must have strong understanding of provider networks, the medical management process, claims processing .
• Must be proficient handling high volume inbound calls.
• Must have background in following up with insurance providers.

I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.

Recruiter Name: Jatin Rattan

Title: Senior Recruiter

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