Medical Appeals & Grievances Specialist
Robert Half Los Angeles
A Medical IPA is in the need of a Medical Appeals & Grievances Specialist. The Medical Appeals & Grievances Specialist will be part of a team focused on managing denied claims and ensuring compliance with State/Federal laws, rules, and guidelines.
The role involves regular interaction with health care providers, medical insurance companies, and related governmental agencies, and requires extensive knowledge of claim administration and the ability to work independently.
Responsibilities:
- Investigate, document, and resolve denied claims in compliance with State/Federal law, rules, and guidelines.
- Conduct research and utilize extensive claims knowledge to respond to inquiries and interpret plan/policy provisions.
- Write determination letters regarding the outcome of non-clinical reviews/claim denials and correspond with participants and providers via email and telephone.
- Research incoming correspondence related to claim denials and determine necessary next steps.
- Assist with the preparation of Benefits Committee appeal cases.
- Develop guidelines for examiners to use in evaluating whether certain types of claims may require review.
- Work collaboratively with legal counsel on cases as directed by Management.
- Provide guidance to Participant Services Representatives on calls regarding medical claims issues.
- Recommend changes to management on Health Plan language for medical benefits.
- Minimum of 2 years of experience in a similar role
- Medical Claims
- Medical Appeals
- Medical Grievances
- Medical Billing
Mens Health FoundationLos Angeles
offer the following:
• Medical, Dental, Vision, Life, and LTD insurance (may be eligible on the 1st of the month following the date of hire)
• 12 Paid Holidays (including one mental health day)
• 401(k) Retirement plan (may be eligible for employer...
SJS Executives LLCLong Beach, 10 mi from Los Angeles
SJS Executives, LLC (SJS), also doing business as SJS Industrial, is seeking a meticulous, and detail-oriented Medical Equipment Planner who will work in Long Beach, California location providing equipment planning duties for a local VA Hospital...
Comprehensive Community Health Centers Inc.Glendale (CA), 14 mi from Los Angeles
Description:
CLINIC STAFF TRAINER (CERTIFIED MEDICAL ASSISTANT/LVN) JOB SUMMARY
Under the direction of the Nurse Administrator, functions as the Support Staff Trainer, performing outlined duties. The Support Staff Trainer must assist...