Job Description

Job Title: Claims & Appeals Specialist – Medicare/Medicaid

Must be able to pick up equipment and do first week of training onsite in the West Village- then it is remote after that!

Overview

We are seeking an experienced Claims & Appeals Specialist to join our team. The ideal candidate will have in-depth knowledge of Medicare and Medicaid rules and regulations, exceptional problem-solving skills, and strong attention to detail. In this role, you will investigate and process claims, ensuring compliance with all department, plan, and regulatory requirements for accuracy, timeliness, and quality service.

Key Responsibilities

• Review, investigate, and adjudicate claims in accordance with CMS, DOH, and plan guidelines.
• Communicate and follow up with internal and external stakeholders to resolve claim issues.
• Evaluate claims to ensure payment accuracy and alignment with services rendered.
• Review suspended claims for correct HCPCS codes, units, and service dates.
• Analyze medical information to determine Coordination of Benefits (COB) and work with other carriers as needed.
• Resolve claims-related issues involving Medical Management, Network Development Services, Enrollment, and Customer Services.
• Recommend process improvements to enhance claims processing efficiency.
• Respond to inquiries from members and providers.
• Oversee claims appeals handling, ensuring timely and accurate resolution for all lines of business.
• Conduct monthly audits of third-party administrator (TPA) appeals reports and service logs for accuracy.
• Participate in CMS audits, ensuring proper documentation, data validation, and compliance.
• Provide regular reporting on Medicare Part C Appeals metrics to the Compliance Department.
• Identify training needs and assist in delivering training to internal teams, external partners, and TPA staff.
• Participate in special projects and perform other related duties as assigned.

Qualifications

• Two years of college or equivalent combination of education and relevant work experience.
• At least 4 years of claims processing experience, preferably in an HMO or Medicare managed care environment.
• Knowledge of medical terminology, ICD-10, CPT, HCPCS coding, and EncoderPro.
• Strong ability to work independently with high productivity.
• Excellent written and verbal communication skills.
• Advanced proficiency in Microsoft Excel; experience with Microsoft Access preferred.

Why Join Us?

This is an opportunity to apply your expertise in claims and appeals to improve processes, ensure compliance, and contribute to a mission-driven organization serving diverse populations.

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