Medical Appeals & Grievances Specialist

Description 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.Requirements Minimum of 2 years of experience in a similar role Medical Claims Medical Appeals Medical Grievances Medical BillingRobert Half is the world’s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app (https://www.roberthalf.com/us/en/mobile-app) and get 1-tap apply, notifications of AI-matched jobs, and much more.All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.© 2024 Robert Half. An Equal Opportunity Employer. M/F/Disability/Veterans. By clicking “Apply Now,” you’re agreeing to Robert Half’s Terms of Use (https://www.roberthalf.com/us/en/terms) .