Appeals Examiner - Hybrid (Remote Eligible After 90 Days) - West Sacramento, CA
About The Position
The Appeals Examiner reviews, researches, and resolves healthcare provider appeals related to medical claims and payment determinations. The role analyzes appeal documentation, researches claim payment issues, and ensures each appeal is reviewed accurately and completely in accordance with established guidelines, policies, and regulatory requirements. The position supports California's Medi-Cal program by ensuring provider appeals and medical claims are researched and resolved accurately and in a timely manner. The role is onsite in West Sacramento, California, for the first 90 days. After 90 days, employees may be eligible to transition to fully remote work based on performance, productivity, quality standards, management approval, and business needs. The work schedule is 6:00 a.m. to 2:30 p.m. Pacific Time.
Requirements
- Two or more years of medical claims and/or appeals experience.
- Experience researching and resolving healthcare claim payment issues.
- Experience working with health insurance and medical terminology.
- Strong research, analytical, and problem-solving skills, with exceptional attention to detail and accuracy.
- Ability to interpret claims information, appeal documentation, policies, and procedures to determine appropriate resolutions.
- Ability to work effectively in a production-focused environment while meeting established quality and productivity expectations.
- Proficiency with Microsoft Outlook, Word, Excel, Teams, and related business systems.
Responsibilities
- Review and research provider appeals using established guidelines, and document determinations clearly, accurately, and concisely.
- Analyze medical claims, appeal documentation, payment information, and supporting records to ensure all aspects of an appeal have been addressed.
- Research and resolve claim payment issues, identify discrepancies, and determine appropriate actions based on established policies and procedures.
- Resubmit or adjust claims for approved appeals, completing appropriate claim corrections and supporting documentation.
- Manage assigned appeals through resolution while meeting productivity, accuracy, and quality standards.
- Protect confidential information and comply with HIPAA and applicable organizational and regulatory requirements.
Benefits
- Flexible vacation policy for eligible salaried, full-time candidates.
- 401(k) employer match.
- Comprehensive health benefits.
- Educational assistance.
- Leadership and technical development academies.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
