Appeals Specialist (Medicare)

AmeriHealth Caritas; Philadelphia (Philadelphia County); Hybrid; USD 45,000 - 70,000; Full time

Job summary

An established industry player is seeking a dedicated Appeals Specialist to join their team. In this role, you will coordinate and perform all appeal-related duties, ensuring compliance with Medicare and Medicaid regulations. Your expertise will help resolve service denials while working collaboratively with medical management staff and providers. This position offers the chance to make a significant impact in the lives of individuals by ensuring they receive the care they need. Join a mission-driven organization that values diversity, equity, and inclusion, and be part of a team that champions healthy communities.

Benefits

Flexible work solutions

Remote options

Competitive pay

Paid time off

Health insurance from Day 1

401(k)

Tuition reimbursement

Qualifications

• 1-3 years of experience in Medicare appeals resolution in healthcare.
• Strong knowledge of Medicare and Medicaid regulations.

Responsibilities

• Analyze and respond to appeals regarding denials of services.
• Prepare case files for submission to the Independent Review Entity.

Skills

Medicare appeals resolution

Research skills

Communication skills

Problem-solving

Adaptability

Education

Bachelor’s Degree

Equivalent professional experience

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft Access

Adobe Pro

Claims Processing Systems

Job description

Your career starts now. We are looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Position Overview: The Appeals Specialist reports to the Supervisor of Appeals & Grievances and coordinates and performs all appeal-related duties within Medicare Advantage Dual Special Needs and Medicare-Medicaid. This includes handling requests for decisions regarding denials of medical services and Part D drugs.

Key Responsibilities:

• Analyze and respond to appeals from members, member representatives, and providers regarding denials for services and payment, both oral and written, ensuring compliance with all regulatory milestones.
• Research and apply relevant Medicare and Medicaid regulations to determine the outcome of appeals.
• Provide oversight and assistance to Medical Management staff in resolving appeals by interpreting Medicare and Medicaid regulations.
• Review documentation to ensure all appeal aspects are addressed accurately and thoroughly.
• Prepare case files for submission to the Independent Review Entity, including writing position papers on behalf of the plan to support appeal resolution.
• Generate and analyze reports to identify trends in appeal requests and decisions.
• Interacting with the provider to obtain additional clinical information.
• Engage with the member or their advocates to understand the full intent of the appeals or grievance.

Education & Experience:

• Bachelor’s Degree or equivalent professional work-related experience.
• 1 to 3 years of proven experience in Medicare appeals resolution within a Managed Care or Healthcare setting (e.g., physician’s office, medical records, or office triage).
• Demonstrated knowledge of Medicare Advantage, Original Medicare, and Medicaid appeal regulations.
• Proficient knowledge of CPT, HCPCS, and ICD-9 definitions.
• Must be proficient in using Microsoft Word, Outlook, Access, Excel, and Adobe Pro, with accurate typing skills (35 wpm).
• Experience with Claims Processing Systems is highly preferred.
• Exceptional ability to work collaboratively or independently, deliver high-quality work, exhibit intellect, resourcefulness, and curiosity in problem-solving, and demonstrate strong research, communication, and listening skills.
• Must be adaptable to work in a fast-paced environment, thrive on change, and readily accept new assignments and challenges.

Diversity, Equity, and Inclusion

AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve. We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.