What are the responsibilities and job description for the Temp Appeals Specialist position at The Nagler Group?
We are seeking a detail-oriented and experienced Temporary Appeals Specialist to join our team in Portland, ME. This role focuses on processing and managing appeals for Medicare and the US Family Health Plan (USFHP). The Appeals Specialist collaborates with internal and external partners, including Care Managers, Medical Directors, and Compliance teams, to ensure the appeals process is comprehensive and compliant with regulatory standards.
Key Responsibilities
Location: Portland, ME
Hours: Monday-Friday 8:30am-5:00pm
Why Join Us?
This temporary role offers a unique opportunity to work in a dynamic environment, contributing to the well-being of members and providers by ensuring a thorough and compliant appeals process.
How To Apply
Submit your resume directly to Rebecca at rrand@naglergroup.com highlighting your relevant experience and expertise in appeals management. We look forward to hearing from you!
TNG123
*MONTNG*
Key Responsibilities
- Medicare Appeals:
- Research, process, and resolve Part C reconsiderations with 100% compliance.
- Prepare for and participate in CMS, NCQA, and Health Plan audits.
- Serve as a subject matter expert on Medicare Managed Care Manuals.
- USFHP Appeals:
- Research, process, and resolve appeals in accordance with TRICARE and NCQA guidelines.
- Serve as a subject matter expert on TRICARE and USFHP manuals and benefits related to appeals.
- Prepare appeals documentation within contractual and regulatory timelines.
- Manage multiple work queues and correspondence streams independently.
- Evaluate medical claims and coverage policies to determine appeal validity.
- Ensure timely and organized data entry, case file maintenance, and resolution monitoring.
- Conduct telephone correspondence with members, providers, and third-party administrators.
- Develop and maintain case files for clinical review and regulatory requirements.
- Monitor and ensure the effectuation of decisions resulting from appeals.
- Support leadership in developing policies and identifying training opportunities.
- Cross-train to perform Medicare and USFHP appeals functions as needed.
Location: Portland, ME
Hours: Monday-Friday 8:30am-5:00pm
Why Join Us?
This temporary role offers a unique opportunity to work in a dynamic environment, contributing to the well-being of members and providers by ensuring a thorough and compliant appeals process.
How To Apply
Submit your resume directly to Rebecca at rrand@naglergroup.com highlighting your relevant experience and expertise in appeals management. We look forward to hearing from you!
TNG123
*MONTNG*
Salary : $25 - $33
