Medicare Appeals Specialist: Drive Resolution and Impact

Florida Blue Group; Florida; Sur place; USD 28 000 - 45 000; Plein temps

Avantages offerts par ce poste

Medical, dental, vision insurance

Life and disability insurance

Paid time off

Retirement plan with employer match

Holidays and well-being days

Voluntary benefits

Résumé du poste

Florida Blue seeks a Medicare Appeals and Grievances Coordinator to resolve member and provider appeals and grievances in compliance with CMS timelines. You will manage case loads, gather medical records, and coordinate with vendors and partners to reach timely determinations.

Strong Medicare knowledge and data-driven problem solving are essential. You will work across systems like Siebel, JIVA, Diamond, and ProviderConnect to document actions and communicate outcomes to appellants, while

Qualifications

• 3+ years related work experience in Member Contact, Enrollment, Maintenance and Billing (EM&B), Claims or Medicare.
• Experience using Siebel, Diamond, JIVA and other Medicare databases.
• Ability to work flexible schedule with overtime and weekends when needed.
• Medicare product knowledge.
• Ability to work independently and collaboratively as a team member.
• Excellent interpersonal skills and an ability to recognize, understand, and respond to sensitive member issues or concerns.
• Ability to manage multiple priorities, have analytical and problem solving skills with attention to detail.

Responsabilités

• Review appeal and grievance cases from various appellant types in accordance with CMS guidelines and timeframes.
• Classify cases and review for potential expedited requests.
• Resolve complex standard or expedited grievances, appeals or disputes.
• Coordinate with CMS regulatory guidelines and required notices to meet CMS timeframes.
• Prioritize case workload to ensure CMS timeframes and written notifications are met.
• Access various systems to gather pertinent data related to the case and document resolution.
• Research and document pertinent details and attach supporting documents to the case.
• Coordinate with internal partners and gather data or medical records for clinical decisions.
• Ensure notification to the appellant within CMS timeframes.
• Outreach to members, providers, and partners to resolve appeals or grievances.
• Escalate issues to Manager as needed.

Connaissances

Analytical thinking

Problem solving

Communication

Team collaboration

Formation

Bachelor's degree

High school diploma or GED

Outils

Siebel

Diamond

JIVA

ProviderConnect

Client Letter

ERCMS RADMD

Magellan

Blue 2

Description du poste

Florida Blue seeks a Medicare Appeals and Grievances Coordinator to resolve member and provider appeals and grievances in compliance with CMS timelines. You will manage case loads, gather medical records, and coordinate with vendors and partners to reach timely determinations.

Strong Medicare knowledge and data-driven problem solving are essential. You will work across systems like Siebel, JIVA, Diamond, and ProviderConnect to document actions and communicate outcomes to appellants, while