Medicare Claims Appeals Specialist (Full remote) Part-time/Flexible Hours

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
• Flexible hours, 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 contracts, 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 outcomes.
• Request and review medical records, notes, or detailed billing when 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 clarity and accuracy.
• Conduct root cause analysis for payment errors related to provider contracts, fee schedules, and system configurations.
• Provide clear, professional written and verbal communication to members, providers, or authorized representatives regarding resolution outcomes.

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 contracts, DOFR, and claims edits
• Familiarity with Medicaid 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

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