- You will be a part of the Healthcare Claims team which is responsible for the administration of health claims
- This team is involved in core claim processing such as registering claims editing verification claims evaluation and examination litigation
- Includes the administration of health, life, and property & causality claims. • Includes activities involved in core claim processing such as registering claims, editing & verification, claims evaluation, and examination & litigation.
What are we looking for?
- • Graduate degree.
- • 2 to 4 years healthcare operations experience.
• • Experience in Medicare Appeals and Grievances processing.
- • Experience with Medicare Part C and Part D Appeals. • • Knowledge of CMS regulations and turnaround requirements.
Roles and Responsbilities:
- Handle end-to-end appeals processing, ensuring timely and accurate case resolution.
- Perform AOR (Appointment of Representative) validation and provider outreach.
- Review denial rationales and supporting clinical documentation.
- Prepare and organize appeal cases for Medical Director review.
- Process final determinations and complete effectuation activities in accordance with established guidelines.