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Teamware Solutions
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US Healthcare

US Healthcare

Teamware Solutions

2 - 4 years

1 - 4 Lacs

Hyderabad

Posted:4 days ago| Platform:

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Skills Required

Appeals Claims Adjudication Grievance Management US Healthcare Claims Processing

Work Mode

Work from Office

Job Type

Full Time

Job Description

We are seeking a dedicated and detail-oriented Appeals & Grievances Processor with a

strong background in the US healthcare payor sector. This role involves working as part of a

team to resolve complex member and provider issues related to appeals and grievances,

ensuring compliance with Medicare, Medicaid, and health plan standards.

Minimum Qualifications:

2+ years of experience in the US healthcare payor sector.
1+ year of experience in processing appeals and grievances.
Strong understanding of denial management and claims adjudication.
Experience with Medicare and Medicaid from the payor side.

Responsibilities:

Analyze and resolve member and provider appeals, grievances, and disputes in

compliance with regulatory requirements.

Prepare and organize case research, notes, and documents.
Communicate effectively with members and providers, both verbally and in writing.
Obtain and review medical records, notes, and bills to apply contract language and

benefits.

Conduct research and analysis to recommend appropriate actions for management

review.

Determine the root cause of payment errors and resolve them using support

systems.

Compose concise and accurate correspondence regarding appeals and grievances.
Collaborate with provider and member services to address balance bill issues and

complaints.

Ensure timely and appropriate responses per state, federal, and health plan

guidelines.

Meet departmental production standards.
Prepare appeal summaries and document findings, including trend information as

needed.

Preferred Knowledge/Skills:

Strong verbal and written communication skills, including letter writing.

Proficiency in Microsoft Word, Excel, and PowerPoint.
Excellent organizational, interpersonal, and time management skills.
Attention to detail and ability to prioritize tasks and work under firm deadlines.
Enthusiastic team player with the ability to interact successfully with members,

medical professionals, and government representatives.

Familiarity with the Pega computer system is a plus.

Certifications:

No specific certifications required.

Additional Information:

This position requires 100% work from the office.
The role operates during night shifts to accommodate client and organizational

needs.

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