ROLE OVERVIEW

Join the Healthcare Claims team responsible for health claims administration, including claims registration, editing and verification, evaluation, examination and litigation-related support. The broader claims administration scope includes health, life, and property and casualty claims.


REQUIRED SKILLS AND EXPERIENCE

• Graduate in any discipline with 1-3 years of relevant 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.

• Experience in end-to-end appeal processing, AOR validation and provider outreach.

• Ability to review denial rationale and supporting clinical documentation.


ROLES AND RESPONSIBILITIES

• Handle end-to-end appeal processing.

• Perform AOR validation and provider outreach.

• Review denial rationale and supporting clinical documentation.

• Prepare cases for Medical Director review.

• Process determinations and effectuation activities.

• Follow applicable CMS regulations and turnaround requirements.