Impact-Driven Medical Appeals Specialist

Wollborg Michelson Recruiting; Phoenix (AZ); On-site; USD 42,000 - 62,000; Full time

Job summary

Wollborg Michelson Recruiting is seeking a Medical Appeals and Grievances Support Specialist to review, research, and resolve medical and pharmacy appeals and grievances. The role involves examining medical records, claims information, and regulatory requirements to determine case resolution, while maintaining HIPAA compliance.

Applicants should have experience in claims processing or related fields and a background in healthcare documentation.

Qualifications

• At least one year of experience in claims processing, medical or pharmacy precertification, appeals and grievances coordination, or a related field.
• High school diploma or equivalent; higher education acceptable.
• Professional certification such as Coder certification is preferred.

Responsibilities

• Research and resolve medical and pharmacy appeals and grievances from members and providers.
• Review medical records, claims data, and supporting documentation to determine case resolution.
• Process appeals in accordance with state, federal, regulatory, and contractual requirements.
• Prepare case files, communications, and documentation for medical directors and regulatory agencies.
• Monitor appeals channels, identify trends, and assist with quality improvement initiatives.

Skills

Claims processing

HIPAA compliance

Analytical research

Written communication

Customer service

Interpersonal skills

Confidentiality

Team collaboration

Medical terminology

Education

High school diploma

Certified Coder (preferred)

Tools

Claims systems

Pharmacy systems

Medical management systems

Microsoft Office

Job description

Wollborg Michelson Recruiting is seeking a Medical Appeals and Grievances Support Specialist to review, research, and resolve medical and pharmacy appeals and grievances. The role involves examining medical records, claims information, and regulatory requirements to determine case resolution, while maintaining HIPAA compliance.

Applicants should have experience in claims processing or related fields and a background in healthcare documentation.