A Medical Claims Organizations is in the immediate need of Medical Claims Examiner with experience in grievances and appeals to join the team. The Medical Claims Examiner is responsible for reviewing, investigating, and resolving member and provider grievances and appeals in compliance with regulatory requirements and internal policies. The Medical Claims Examine candidate will have hands-on experience working within EZ-CAP and a solid understanding of health plan operations.

Key Responsibilities:

Review, research, and process member and provider grievances and appeals accurately and within required turnaround timesUse EZ-CAP to document, track, and manage case activityAnalyze case details, benefits, claims, authorizations, and supporting documentation to determine appropriate resolutionsEnsure all grievances and appeals are handled in accordance with health plan policies, CMS, DMHC, and other applicable regulatory guidelinesCommunicate with internal departments, providers, and members regarding case status and resolutionPrepare written correspondence for grievance and appeal determinationsMaintain complete, accurate, and audit-ready documentationIdentify trends or recurring issues and escalate as needed