Appeals Specialist I

Lancesoft; United States; Remote; USD 25,000 - 35,000; Full time

Job summary

Lancesoft in the United States seeks an Appeals Specialist I to review and resolve member and provider complaints in line with CMS guidelines and internal standards.

You will research claims, request records, apply contract language, and communicate resolutions to members or providers, ensuring timely responses and proper documentation.

This role requires strong written and verbal communication, attention to detail, and the ability to work within regulated production targets.

Qualifications

• Min. 2 years operational managed care experience (call center, appeals or claims environment).
• Health claims processing background, including COB, subrogation, and eligibility criteria.
• Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Strong verbal and written communication skills.

Responsibilities

• Research and resolve appeals, disputes, grievances, and complaints to meet timelines.
• Research claims appeals and grievances using support systems to determine outcomes.
• Request and review medical records, notes, and bills; determine responses per protocol.
• Meet production standards set by the department.
• Apply contract language, benefits, and review of covered services.
• Contact member/provider through written and verbal communication.
• Prepare appeal summaries, correspondence, and document findings; report trends if requested.
• Compose all correspondence and appeal/grievance information in compliance with regulatory requirements.
• Research processing guidelines, provider contracts, fee schedules, system configurations to determine root cause of payment error.
• Resolve and prepare written response to provider reconsideration requests related to payments.

Skills

Appeals processing

Regulatory knowledge

Communication skills

Research skills

Contract language understanding

Education

High School Diploma or equivalency

Job description

Job Title: Appeals Specialist I

Shift: MONDAY TO FRIDAY 8AM TO 4: 30PM

Contract: 3+ (possible extension or conversion)

Offered Rate: $21.92/hr. On W2 (all inclusive)

Job Summary

Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

KNOWLEDGE/SKILLS/ABILITIES

• Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.
• Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate;formulates conclusions per protocol and other business partners to determine response;assures timeliness and appropriateness of responses per state, federal and Healthcare guidelines.
• Responsible for meeting production standards set by the department.
• Apply contract language, benefits, and review of covered services
• Responsible for contacting the member/provider through written and verbal communication.
• Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
• Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
• Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
• Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies

REQUIRED EDUCATION

High School Diploma or equivalency

REQUIRED EXPERIENCE

• Min. 2 years operational managed care experience (call center, appeals or claims environment).
• Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.
• Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Strong verbal and written communication skills