A Claims Adjuster or Specialist investigates and evaluates insurance claims. Specializes in a particular type of insurance. Inspects property damage, including damage to homes, buildings and cars; reviews claims after they are submitted; may authorize or deny payment for claims. May work directly for insurers or on behalf of claimants.
We are seeking an experienced Appeals & Grievance Specialist II to join a leading healthcare organization in Irving, TX . This position is responsible for independently researching, investigating, and resolving member and provider appeals, grievances, claim denials, and complaints while ensuring compliance with CMS, Medicare, Medicaid, TRICARE, and regulatory requirements. The ideal candidate will have strong managed care experience, knowledge of medical claims, benefit interpretation, CPT/ICD coding, and the ability to work independently in a fast-paced healthcare environment.
Key Responsibilities:
Investigate, research, and resolve member and provider appeals and grievances. Review claim denials, reconsideration requests, and redetermination cases. Interpret health plan benefits, policies, and coverage guidelines. Analyze medical claims and supporting documentation. Utilize CPT, ICD, and healthcare coding knowledge during case reviews. Coordinate with internal departments to resolve complex issues. Ensure compliance with CMS, Medicare, Medicaid, TRICARE, and state/federal regulations. Prepare written determination letters and communicate case outcomes. Maintain accurate documentation of appeal and grievance cases. Analyze grievance trends and prepare tracking and reporting data. Identify root causes and recommend operational process improvements. Support initiatives to improve member satisfaction and Medicare STAR Ratings. Meet quality, productivity, and turnaround time standards.
Minimum Qualifications:
High School Diploma or GED ( Proof of education required ). 3+ years of customer service experience with Managed Care Health Plans. 2+ years of Appeals & Grievance experience with Managed Care Plans. Experience reviewing healthcare claims and benefit determinations. Knowledge of medical terminology. Understanding of CPT, ICD-10, and HCPCS coding. Knowledge of Medicare, Medicaid, CMS, and/or TRICARE regulations.
Conatct:
(484) 212 9040 #Med1
Pay:
$25.00•$32.00 per hour Expected hours: 40.0 per week Application Question(s): Do you have High school Diploma? Have you researched and resolved member and provider appeals, grievances, or complaints? Do you have experience reviewing medical claims, claim denials, reconsiderations, or redeterminations? Do you have working knowledge of CPT, ICD-10, and medical terminology? Are you familiar with Medicare, Medicaid, CMS, or TRICARE regulations?
Email address:
Availability time for call: Reach me directly at (484) 212 9040
