appeals specialist

Powerback Rehabilitation

<div>Overview:
<div><b>
FULL-TIME (REMOTE) CORPORATE DENIALS &amp; APPEALS SPECIALIST</b></div><div></div><div><b><br>
MUST HAVE HEALTHCARE BILLING/COLLECTIONS EXPERIENCE W/CONCENTRATION ON DENIALS / APPEALS</b></div><div></div><div><br>
At Powerback, we're on a mission to improve lives. As the leader in physical, occupational, speech, and respiratory therapies, we help older adults stay active and thrive while providing essential therapy for children at home and in school.</div><div></div><div><br>
With over 38 years of trusted service, our reach spans skilled nursing centers, assisted and independent living facilities, outpatient clinics, and home-based care. We're proud to deliver personalized care exactly where and when it's needed most.</div><div></div><div><br>
Join an industry-leading team that restores hope and makes a lasting impact. If you're passionate about making a meaningful difference and want to be part of the future of rehabilitation and wellness, Powerback is the place for you.</div><div></div><div><b><br>
Why Powerback?</b></div><ul><li><b>
Benefits:</b> We offer Medical, Dental, and Vision plans to Full-Time team members. We offer Dental and Vision to Part-Time team members.</li><li><b>
Paid Time Off</b>: We offer generous paid time off to Full-Time and Part-Time team members.</li><li><b>
Support for New Grads:</b> Our Powerback Clinical Mentorship Program kicks off on day one, helping you learn from the best in the field.</li><li><b>
Continuing Education:</b> Keep growing with free CEUs through Medbridge.</li><li><b>
H-1B Visa &amp; Relocation Assistance:</b> We support Visa or Green Card sponsorships, plus our Journey Travel Program lets you work across the U.S. with the security of a full-time role.</li><li><b>
Perks at Powerback:</b> Enjoy exclusive discounts on Wireless/TV, Home/Auto/Renters and Pet Insurance, Childcare, Eldercare, and more. Earn rewards through our PowerZone Employee Recognition Program, and expand your expertise with our Clinicians in Action professional development program</li></ul>
Responsibilities:
<div><div>The Denials and Appeals Specialist is responsible for the follow up of denied claims from all commercial and contracted payers. The follow up includes initial assessment of the denials received to determine the appropriate process. Once determined, established policy and procedure will be followed for appeal submission.</div><div><br>
Reviews assigned accounts that have a payer denial based on the response from the payer and takes appropriate action, including appeals, based on the type of denial.</div><div>
Documents all necessary elements; reason for denial/audit, denial status, and action taken in the electronic medical record per denial management policy.</div><div>
Provides missing or additional information if necessary, to expedite the resolution of the denied claim. This may include writing detailed appeal letters supporting the claim and reimbursement.</div><div>
Performs all appeals and denials recovery procedures needed to appropriately and accurately resolve denied claims. This includes working with internal and external customers.</div><div>
Consistently meets productivity and quality standards established by management, recommending new approaches for enhancing performance and productivity when appropriate.</div><div>
Keeps Supervisor/Manager informed of any problems or issues related to the appeal process and/or current appeals.</div><div>
Performs other duties as assigned.</div></div>
Qualifications:
<div><ul><li>High School diploma or equivalent education and experience required. College degree preferred.</li><li>Must be proficient using MS Office or Google Suite applications.</li><li>Strong analytical skills.</li><li>Minimum of 1 - 2 years of previous revenue cycle management experience.</li></ul></div>
Posted Salary Range: USD $20.00 - USD $20.00 /Hr.</div>

Denials and Appeals Specialist

Mutual of Omaha

<div><div><p><b>Location:</b> Remote<br>
<b>Work Type:</b> Full Time Regular<br>
<b>Job No:</b> 504643<br>
<b>Categories:</b> Claims/Claims Processing<br>
<b>Application Closes:</b> Closes Mar 31, 2026
</p><div>2026-03-13</div></div><div></div><div><br>
</div><div></div><div><div><div><div><div>In this role, you&rsquo;ll leverage your expertise in claims adjudication, contract interpretation, and risk management to guide clients, overcome obstacles, and ensure fair, compliant decisions. You&rsquo;ll collaborate with internal teams and the Law Division, communicate clearly and professionally with claimants and stakeholders, and manage multiple priorities with accuracy and attention to detail. This role also offers the opportunity to mentor and support staff while continuously improving processes and efficiency.</div></div><br>
<div>
<div><p><b>WHAT WE CAN OFFER YOU:</b></p>
<div>
<ul><li>Estimated Salary: (Levels have variable responsibilities and qualifications):
<ul><li>Appeals Specialist: $54,000 - $66,000 plus annual bonus opportunity.
</li><li>Sr Appeals Specialist: $68,000 - $90,000 plus annual bonus opportunity.
</li></ul></li><li>401(k) plan with a 2% company contribution and 6% company match.
</li><li>Work-life balance with vacation, personal time and paid holidays. See our benefits and perks page for details.
</li>Applicants for this position must not now, nor at any point in the future, require sponsorship for employment.<br>
<li>
</li></ul></div></div></div><br>
<div><div><p><b>WHAT YOU'LL DO:</b></p>
<div>
<ul><li>Reviews and evaluates all pre- and post-adverse benefit determination materials for Group STD, LTD, Life, AD&amp;D, Waiver of Premium, CI and Accident appeals; overcomes objections through effective appeal arguments, escalates appropriately, and requests additional information as needed to clarify issues.</li>
<li>Renders appeal decisions using medical, vocational and legal risk management resources; serves as a technical expert to guide client appeal activities and leverages contract language to support sound determinations.</li>
<li>Prepares clear, professional written communications to claimants, representatives, policyholders, brokers and attorneys; documents actions thoroughly and maintains accurate records of appeal cause, disposition and trending.</li>
<li>Ensures compliance with ERISA and applicable federal and state laws; researches and evaluates emerging case law and regulatory changes, presents cases in forums, and remains current on company, industry and legislative updates.</li>
Drives continuous improvement by identifying technological and process enhancements; mentors and trains staff and clients on appeals and risk management, contributes to internal policy development, and partners with operations to ensure alignment on key processes.<br>
<li>
</li></ul></div></div></div><br>
<div><div><p><b>WHAT YOU&rsquo;LL BRING:</b></p>
<div>
<ul><li>Minimum of 10 years of Group Disability experience, thorough understanding of claims adjudication, benefit determination, investigation, file development, legal requirements, and contract interpretation, with the ability to conduct focused and extensive claims research.</li>
<li>Demonstrated high-level risk management, analytical, mathematical, problem-solving, and decision-making skills, with strong persuasion, negotiation, and ability to interpret and communicate disability contract language.</li>
<li>Excellent communication skills with the ability to remain professional and pleasant in interactions with coworkers, clients, claimants, vendors, and others; capable of conducting small group presentations and collaborating with the Law Division, including potential participation in depositions or trials.</li>
<li>Ability to de-escalate situations on a regular basis and manage multiple priorities effectively.</li>
<li>Superior attention to detail, flexibility, and the ability to work independently or as part of a team.</li>
<li>You promote a culture of diversity and inclusion, value different ideas and opinions, and listen courageously, remaining curious in all that you do.</li>
<li>Able to work remotely with access to a high-speed internet connection and located in the United States or Puerto Rico.</li></ul></div><br>
</div>
</div><br>
<div><div><p><b>We value diverse experience, skills, and passion for innovation. If your experience aligns with the listed requirements</b></p>
<p>
If you have questions about your application or the hiring process, email our Talent Acquisition area at careers@mutualofomaha.com. Please allow at least one week from time of applying if you are checking on the status.</p>
<p><b>
Stay Safe from Job Scams</b><br>
Mutual of Omaha only accepts applications from mutualofomaha.com/careers. Legitimate communications will come from '@mutualofomaha.com.' We never request sensitive information or extend job offers without conducting interviews. For more details, check our Hiring FAQs. Stay alert for scams and apply securely!</p>
<p>
Fair Chance Notices</p>
</div>
</div><br>
</div></div></div><div>Need help? Email Us
</div><div><div><h2 class="jobSectionHeader"><b>Great place to work</b></h2>
<p>Together we achieve greatness. Not only is this a core value, but it&rsquo;s also representative of the kind of place we are &mdash; built by the strength and integrity of our employees. It&rsquo;s why we&rsquo;re named a &ldquo;Great Place to Work&rdquo;.</p><br>
<p></p>
</div><div><h2 class="jobSectionHeader"><b>An inclusive culture</b></h2>
<p>Surround yourself with an authentic and inclusive culture. Your strengths and differences will be valued and celebrated by a diverse community of co‑workers.</p></div></div></div><p></p>

Appeals Specialist (Group Claims)

Temp Experts

<div><b>Revenue Cycle Management Appeals Specialist</b><br>
<b>Clearwater, FL</b><br>
<b>Onsite | Full-time</b><br>
<br>
TempExperts is seeking<b> </b>motivated professionals for a <b>long-term Revenue Cycle Management project</b> with a rapidly growing medical technology organization in <b>Clearwater, FL</b>. This is an excellent opportunity to make a real impact on patients&rsquo; lives, gain valuable healthcare industry experience, and work in a collaborative, mission-driven environment offering stability and long-term potential. The role focuses on helping cardiac and orthopedic patients access life-changing medical products and resolving insurance claims.<br>
<br>
<b>Responsibilities:</b>
<ul><li>Manage and resolve denied insurance claims through detailed appeals.
</li><li>Contact insurance carriers to determine reasons for denials and pursue resolution.
</li><li>Research, analyze, and document claim information accurately and efficiently.
</li><li>Collaborate with internal departments to gather and submit supporting documentation.
</li><li>Track appeal outcomes and maintain organized, up-to-date records.
</li></ul><b>Requirements/Education:</b>
<ul><li>Confident, professional communicator comfortable resolving issues by phone.
</li><li>Determined, goal-oriented, and accountable individual.
</li><li>Adaptable and comfortable in a fast-paced environment.
</li><li>Detail-oriented with strong multitasking and prioritization skills.
</li><li>Dependable team player who thrives on achieving results.
</li></ul><i>TempExperts is an Equal Opportunity Employer.</i></div>

Revenue Cycle Management Appeals Specialist

Aspirion

<div>Description:
<p>
For over two decades, Aspirion has delivered market-leading revenue cycle services. We specialize in collecting challenging payments from third-party payers, focusing on complex denials, aged accounts receivables, motor vehicle accident, workers&rsquo; compensation, Veterans Affairs, and out-of-state Medicaid.</p><p>
At the core of our success is our highly valued team of over 1,400 teammates as reflected in one of our core guiding principles, &ldquo;Our teammates are the foundation of our success.&rdquo; United by a shared commitment to client excellence, we focus on achieving outstanding outcomes for our clients, aiming to consistently provide the highest revenue yield in the shortest possible time.</p><p>
We are committed to creating a results-oriented work environment that is both challenging and rewarding, fostering flexibility, and encouraging personal and professional growth. Joining Aspirion means becoming a part of an industry leading team, where you will have the opportunity to engage with innovative technology, collaborate with a diverse and talented team, and contribute to the success of our hospital and health system partners. Aspirion maintains a strong partnership with Linden Capital Partners, serving as our trusted private equity sponsor.</p><p>
We are seeking an Appeals Specialist to join our growing team. As an Appeals Specialist, you will contribute to our fast-paced, collaborative environment and will bring your expertise to deliver exceptional billing services for our clients. The ideal candidate will have strong technical skills, excellent communication and healthcare experience in a hospital and a professional billing or coding environment. A successful Appeals Specialist must be able to perform each responsibility satisfactorily. The following responsibilities represent the strong knowledge, skills and abilities required to perform the job successfully and independently.
 </p><p><b>Key Responsibilities</b></p><ul><li>
Review/work denials from an explanation of benefits (EOB) statement</li><li>
Analyze A/R (Accounts Receivable) reports to follow up on unpaid claims</li><li>
Compose and submit appeals to insurance companies</li><li>
Submit required documentation to insurance companies as requested</li><li>
Research claims for information to process bills in a timely manner</li><li>
Communicate with insurance companies, adjustors and patients on a regular basis</li><li>
Correct errors and resubmit all unprocessed or returned claims to insurance companies</li><li>
Correct UB04 and HCFA bills</li><li>
Maintain productivity standards</li><li>
Perform other duties as assigned by Direct Report
</li></ul>Requirements:
<ul><li>2+ years of healthcare billing and denials experience</li><li>
Strong healthcare industry knowledge including basic coding principals</li><li>
Demonstrated ability to troubleshoot and remedy claims denials or submission errors</li><li>
Demonstrated ability to interpret claims data in internal billing software and diverse EHR&rsquo;s</li><li>
Prior experience using Microsoft Office Suite</li></ul><p><b>
Education and Experience</b></p><ul><li>
High School Diploma or GED required; bachelor's degree preferred</li><li>
Previous work from home experience</li></ul><p><b>
Benefits</b></p><p>
At Aspirion we invest in our employees by offering a full benefits package, including health, dental, vision and life insurance upon hire, matching 401k, competitive salaries, advancement opportunities, and incentive programs.</p><p>
The US base pay range for this position <b><i>starts</i></b> at $19.00 hourly. <i>Individual pay is determined by a number of factors including, but not limited to, job-related skills, experience, education, training, licensure or certifications obtained. Market, location and organizational factors are also considered.</i> In addition to base salary, a competitive benefits package is offered.</p><p><b>
AAP/EEO Statement</b></p><p>
Equal Opportunity Employer/Drug-Free Workplace: Aspirion is an Equal Employment Opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, age, sex, pregnancy, religion, national origin, ancestry, medical condition, marital status, gender identity citizenship status, veteran status, disability, or veteran status. Aspirion has a Drug-Free Workplace Policy in effect that is strictly adhered to.</p><p>
Please note that this position is contingent upon the successful completion of a pre-employment drug screening and background check. These steps are part of our standard hiring process to ensure a safe and compliant workplace.</p></div>

Appeals Specialist - Hospital Billing, AR

Caloptima

<div><div><b>Grievance Resolution Specialist Sr (Provider Resolution)</b><br>
<br>
<b>CalOptima</b></div><br>
<b>
Join Us in this Amazing Opportunity</b><br>
<br>
<b>The Team You'll Join</b><br>
<br>
We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.<br>
<br>
<b>More About the Opportunity</b>
<br>
<br>
We are hoping you will join us as a <b>Grievance Resolution Specialist Sr (Provider Resolution)</b> and help shape the future of healthcare where you'll be an integral part of our <b>Grievance &amp; Appeals </b>team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be <b>Full Telework</b>.
<br>
<ul><li><i>If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.</i>
</li></ul><br>
You will coordinate the overall process of complaint resolution, responding to all verbal and written complaints from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, pharmacy and vision decisions. You will have frequent external contact with members and families, health care providers, organizations and regulators. In addition, you will frequently interact with internal contacts in Claims Administration, Customer Service, Provider Relations, Contracting, Pharmacy Management, Third-Party Administrators, Medical Management, health networks and other resources to identify the factors necessary for optimal resolution of complaints. You will be responsible for processing complex cases requiring additional research or problem-solving. You will process 1st and 2nd Level provider appeals in accordance with Department of Health Care Services (DHCS) and Centers for Medicare &amp; Medicaid Services (CMS) guidelines and regulations. Together, we are building a stronger, more equitable health system.
<br>
<br>
<b>Your Contributions To the Team:</b>
<br>
<ul><li>75% - Program Support
<ul><li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Develops and maintains adequate information systems to assure timely and effective data collection, summarization, integration and reporting, including case creation, management and events/activity tracking.</li>
<li>Ensures compliance with CalOptima Health's Grievance Policy and timely case resolution, initiates and coordinates referrals to the Quality Improvement department as necessary and facilitates response to members according to policy.</li>
<li>Handles escalated issues from providers, as well as internal and external customers.</li>
<li>Gathers pertinent information regarding complaints, including member or provider concerns, claims payments, billing reimbursements, supporting information related to initial decisions, new information supporting complaints and supplemental information required to evaluate complaints and regulatory requirements.</li>
<li>Coordinates and participates in case discussions with operational experts to result in a final case disposition.</li>
<li>Reviews government claim cases and determines resolution and recommendation based on researched claims, Provider Dispute Resolution (PDR) and 2nd Level appeal analyses.</li>
<li>Evaluates case details related to member or provider complaints and makes appropriate decisions based on information provided and research conducted.</li>
<li>Provides a summary of GARS cases requested by Legal Affairs or other departments.</li>
<li>Provides subject matter expertise and trains new and existing staff as needed.</li>
<li>Assists with case assignment, assumes cases assignments per business needs and monitors the daily operations for member and provider complaints, ensuring compliance with the implementation of the decision.</li>
<li>Contacts appropriate parties to request and obtain missing information and supporting documentation or provides education.</li>
<li>Oversees resolution letters for accuracy of information and appropriate decisions.</li>
<li>Meets performance measurement goals for GARS.</li>
Supports with provider appeals audits by reviewing findings, gathering and organizing requested materials and completing rebuttals.<br>
<li>
<br>
<br>
</li></ul></li><li>20% - Administrative Support
<ul><li>Participates in meetings regarding case assignment issues and collaborates with cross-department teams to maintain current knowledge of organizational processes and guidelines to effectively resolve cases.</li>
<li>Reads and interprets provider contracts, Division of Financial Responsibility (DOFR), policies, procedures and instructions.</li>
<li>Responds to routine provider inquiries via phone and assists with provider appeals resolution inquiries.</li>
<li>Tracks and trends provider appeals and claims issues.</li>
Supports all department initiatives in improving overall efficiency.<br>
<li>
<br>
<br>
</li></ul></li><li>5% - Completes other projects and duties as assigned.
</li></ul><br>
<b>Do You Have What the Role Requires?</b><br>
<ul>
<li>High school diploma or equivalent PLUS 3 years of experience with Provider Non-Contracted Medicare Post-Service appeals and denials required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.<br>
</li>
<li>3 years of experience with PDR in Medicare and Medi-Cal in Professional, Institutional, Outpatient, Ancillary, Coordination of Benefits and Government Cases required.
<br>
</li><li>Experience with Medicare or Medi-Cal provider appeals and denials process required.<br>
</li>
<li>Experience in health care practice standards, for both government and commercial plans required.<br>
</li>
<li>Experience with claims administration required.</li>
</ul><br>
<b>You'll Stand Out More If You Possess the Following:</b><br>
<ul>
<li>Associate's degree in health care administration or related field.<br>
</li>
<li>Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).</li>
</ul><br>
<b>What the Regulatory Agencies Need You to Possess?</b><br>
<ul>
<li>N/A</li>
</ul><br>
<b>Your Knowledge &amp; Abilities to Bring to this Role:</b><br>
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
</li><li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul><br>
<b>Your Physical Requirements (With or Without Accommodations):</b><br>
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul><br>
<b>Ways We Are Here For You</b><br>
<ul>
<li>You'll enjoy competitive compensation for this role.
<ul><li>Our current hiring range is: Pay Grade: <b>306 - $58,205 - $90,217 ($27.98 - $43.3736).
</b><ul><li><b><i>The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.</i></b><br>
</li>
</ul></li></ul></li><li>This position is approved for <b>Full Telework </b><i>(**If the position is Telework, it is eligible in California only**)</i>
</li><li>A <b>comprehensive benefits package</b>
</li><li>CalPERS pension program and additional retirement packages.
</li><li>Additional benefits and perks including:
<ul><li>A generous PTO program</li>
<li>A quality work life balance</li>
<li>Various wellness programs</li>
<li>Tuition Reimbursement</li>
<li>Professional development opportunities</li>
<li>Career development opportunities</li>
<li>Flexible scheduling</li>
<li>And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.</li>
</ul></li></ul><br>
<b>Our Work Environment:</b><br>
<br>
If located at the 500, 505 Building or a remote work location:<br>
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul><br>
If located at PACE:<br>
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul><br>
If located in the Community:<br>
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
</li><li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul><br>
<b>Why Join Us?</b><br>
<br>
We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.<br>
<br>
<b>What's Your Next Step?</b><br>
<br>
All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is <b>April 1, 2026 at </b><b>9:00 PM (PST). </b><b>We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.</b>
<br>
<br>
<b>Our Commitment to You</b><br>
<br>
<b>Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.</b><br>
<br>
If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet.<br>
<br>
We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process.
<br>
<br>
<i>CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.</i><br>
<br>
<i>CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.</i><i>
</i><br>
<br>
<i>If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.</i><br>
<br>
<b>To apply, please visit: </b><b>https://jobs.caloptima.org/jobs/grievance-resolution-specialist-sr-provider-resolution-505-city-parkway-west-california-united-states</b><br>
<br>
jeid-9f97bae4154ec349812fc00e682610dd</div>

Grievance Resolution Specialist Sr (Provider Resolution)

Amerit Consulting

<div>
 <p>
  <strong>
   <u>
    OVERVIEW:
   </u>
  </strong>
 </p>
 <p>
  <strong>
   Our client, a US Fortune 50 organization and a leading provider of Healthcare and Health Insurance services
  </strong>
  , seeks an accomplished
  <strong>
   Medical Claims Specialist
  </strong>
  .
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    IMPORTANT NOTES: REMOTE / WORK-FROM-HOME RELATED:
   </u>
  </strong>
 </p>
 <ul>
  <li>
   <strong>
    This will be a Remote role.
   </strong>
  </li>
  <li>
   <strong>
    Equipment's will be provided.
   </strong>
  </li>
  <li>
   MUST have high-speed wired Internet connection. Wi-Fi / Wireless connections are not allowed.
  </li>
  <li>
   MUST have a reliable home-office environment.
  </li>
  <li>
   <strong>
    Payrate would be $18.15 per hour. The worker must also receive an additional $5.55 per hour payment in lieu of benefits. Total hourly Pay rate would be $23.70 per hour.
   </strong>
  </li>
  <li>
   <strong>
    Training Shift Hours: 40 hours per week | 08:00am to 4:30pm (Eastern Time).
   </strong>
  </li>
  <li>
   <strong>
    Training will be 5-6 weeks.
   </strong>
  </li>
  <li>
   <strong>
    After training, the candidates may choose to flex start time of 6:00 AM to 10:00 AM (Eastern Time).
   </strong>
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Client will be considering candidates MUST sit within 50 miles of below location (Please apply accordingly):
   </u>
  </strong>
 </p>
 <ul>
  <li>
   Dennison, TX
  </li>
  <li>
   Atlanta, GA
  </li>
  <li>
   Midland/Columbus, GA
  </li>
  <li>
   Indianapolis, INDIANA
  </li>
  <li>
   Louisville, KY
  </li>
  <li>
   Gilbert, MN
  </li>
  <li>
   St Louis, MO
  </li>
  <li>
   Winston-Salem, NC
  </li>
  <li>
   Cincinnati, OH
  </li>
  <li>
   Columbus, OH
  </li>
  <li>
   Mason, OH
  </li>
  <li>
   Nashville, TN
  </li>
  <li>
   Norfolk, VA
  </li>
  <li>
   Richmond, VA
  </li>
  <li>
   Roanoke, VA
  </li>
  <li>
   Baltimore, MD
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Responsibilities:
   </u>
  </strong>
 </p>
 <ul>
  <li>
   This is an entry level position in the NGS Appeals Department that reviews, analyzes and
   <strong>
    processes non-complex pre-service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (Part A &amp; B)
   </strong>
   related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
  </li>
  <li>
   Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
  </li>
  <li>
   Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
  </li>
  <li>
   The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements.
  </li>
  <li>
   As such, the analyst will strictly follow department guidelines and tools to conduct their reviews.
  </li>
  <li>
   Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
  </li>
  <li>
   Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
  </li>
  <li>
   The analyst may serve as a liaison between grievances &amp; appeals and /or medical management, legal, and/or service operations and other internal departments.
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Required Qualifications:
   </u>
  </strong>
 </p>
 <ul>
  <li>
   <strong>
    Must have High School Diploma or GED.
   </strong>
  </li>
  <li>
   <strong>
    Must have 3-4 years&rsquo; experience working with Medical Claims, grievances and appeals, Medicare, Part A OR PART B.
   </strong>
  </li>
  <li>
   <strong>
    Familiarity with medical terminology, demonstrated business writing proficiency.
   </strong>
  </li>
  <li>
   Must have strong understanding of provider networks, the
   <strong>
    medical management process
   </strong>
   ,
   <strong>
    claims processing
   </strong>
   .
  </li>
  <li>
   Must be proficient handling
   <strong>
    high volume
   </strong>
   <strong>
    inbound calls
   </strong>
   .
  </li>
  <li>
   Must have background in
   <strong>
    following up with insurance providers
   </strong>
   .
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <em>
    I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.
   </em>
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Recruiter Contact Info
  </strong>
 </p>
 <p>
  Jatin Rattan
 </p>
 <p>
  E-mail: jatin.rattan@ameritconsulting.com
 </p>
 <p>
  www.ameritconsulting.com
 </p>
 <p>
  <br/>
 </p>
 <p>
  <em>
   I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.
  </em>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Company Overview:
  </strong>
 </p>
 <p>
  Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally; as well as small to mid-sized organizations on a local &amp; regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients&rsquo; businesses forward.
 </p>
 <p>
  <br/>
 </p>
 <p>
  Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
 </p>
 <p>
  <br/>
 </p>
 <p>
  This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws.
 </p>
</div>


Medical Claims Specialist

Growth Ortho

<div><p><b>Revenue Cycle Reimbursement Specialist</b></p><p></p><p><b><br>
Position Overview:</b><br>
Reporting to the Director of Reimbursement, the Revenue Cycle Specialist is responsible for managing and resolving outstanding claims to achieve maximum reimbursement. This role requires strong knowledge of medical collections, accounts receivable, insurance billing and verification, denial management, appeal submission, and EOB review.</p><p></p><p><b><br>
Responsibilities:</b></p><ul><li> Timely follow-up and resolution on all outstanding A/R including unpaid/underpaid/denied claims for all payers including self-pay to obtain maximum reimbursement.</li><li> Manage daily work queue to prioritize high dollar claim balances.</li><li> Review &amp; work incoming insurance and patient correspondence including refund requests.</li><li> Send appeals when appropriate or provide the requested medical documentation.</li><li> Ability to review medical documentation to justify medical necessity.</li><li> Review patient balances to ensure accuracy and follow up with patients to obtain payments.</li><li> Take incoming patient phone calls to resolve inquiries, billing issues, or outstanding balances.</li><li> Review insurance payments and determine accuracy of reimbursement based on contracts, fee schedules or summary plan documents.</li><li> Leverage knowledge of Medicare, state Medicaid, and local coverage determinations (LCD&rsquo;s) for claim resolution.</li><li> Negotiate payment amounts for procedures with Third Party Administrators for out of network providers.</li><li> Recommend an adjustment when applicable or recommend a refund for overpayments to insurance carriers or patients, providing the appropriate documentation.</li></ul><p></p><p><b><br>
Requirements:</b></p><ul><li> 2+ years of ASC and/or orthopedic revenue cycle OR orthopedic collections experience<b>.</b></li><li> Ability to read and interpret insurance explanations of benefits and managed care contracts.</li><li> Must communicate effectively, both verbally and in writing, with internal and external clients.</li><li> Must be able to multi-task and handle competing priorities while meeting or exceeding deadlines</li><li> Knowledge or experience working with a variety of health care insurance payers is preferred</li><li> Intermediate computer proficiency in Microsoft Office including Excel and Outlook</li><li> Greenway Intergy, MedInformatix, and/or Nextgen Practice Management experience a plus but not required.</li><li> High School Diploma or equivalent.</li></ul></div>

Revenue Cycle Reimbursement Specialist

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