Healthcare Claims Appeals Associate – Medicare Appeals & Grievances

Healthcare Claims Appeals Associate - Medicare Appeals & Grievances

Job Reference: AIOC-S

Location: Mumbai, India

Employment Type: Permanent

Work Arrangement: Work from Office

Work Schedule: US Shift

Experience: 1-3 Years

Education: Any Graduate

Notice Period: Up to 45 Days

Process: Non-Voice

Role Overview

We are seeking a detail-oriented Healthcare Claims Appeals Associate to join our healthcare operations team in Mumbai. The successful candidate will be responsible for managing end-to-end healthcare claims appeals and grievances, with a specific focus on Medicare Part C and Part D.

This role involves reviewing appeal requests, validating supporting documentation, assessing claim denial rationale, coordinating with providers, and ensuring accurate and timely case resolution in compliance with applicable Centers for Medicare & Medicaid Services (CMS) guidelines and regulatory turnaround requirements.

Key Responsibilities

- Manage end-to-end Medicare appeals and grievances processing in accordance with established procedures and regulatory requirements.

- Handle Medicare Part C and Part D appeal cases, ensuring accurate documentation and timely resolution.

- Perform Appointment of Representative (AOR) validation and verify relevant authorization documents.

- Conduct provider outreach to obtain missing information and supporting clinical documentation.

- Review claim denial rationales and evaluate supporting medical and clinical records.

- Prepare and organize appeal cases for Medical Director review and determination.

- Process appeal determinations and complete necessary effectuation activities.

- Ensure compliance with CMS regulations, turnaround times, quality standards, and operational guidelines.

- Maintain accurate case records and documentation throughout the appeals lifecycle.

- Identify discrepancies, resolve documentation gaps, and escalate complex cases when necessary.

Required Qualifications & Experience

- Bachelor's degree or graduation in any discipline.

- 1-3 years of relevant experience in healthcare operations, preferably in claims administration.

- Hands-on experience in Medicare Appeals and Grievances processing.

- Strong working knowledge of Medicare Part C and Part D appeals.

- Understanding of CMS regulations, compliance requirements, and turnaround times.

- Practical experience in end-to-end appeals processing.

- Experience with AOR validation and provider outreach.

- Ability to interpret claim denial rationales and review supporting clinical documentation.

- Strong attention to detail, analytical skills, and documentation accuracy.

- Good written communication and coordination skills.

Preferred Skills

- Experience in US healthcare or health insurance operations.

- Familiarity with claims administration and appeals workflows.

- Ability to manage multiple cases while meeting strict turnaround timelines.

- Strong understanding of healthcare documentation and regulatory compliance.

- Ability to work independently in a target-driven, quality-focused environment.

Work Requirements

- Must be willing to work from the office in Mumbai.

- Must be comfortable working US shifts.

- Must be available to join within 45 days.

- Must be comfortable working in a non-voice healthcare operations process.

Ideal Candidate Profile

Candidates with direct experience in Medicare Part C and Part D Appeals and Grievances, CMS compliance, AOR validation, and end-to-end appeals management are strongly encouraged to apply.

• Experience

  1 - 4 Years

• No. of Openings

  10

• Education

  Diploma

• Role

  Healthcare Claims Appeals Associate

• Industry Type

  Hospitals / Medical / Healthcare Equipments

• Gender

  [ Male / Female ]

• Job Country

  India

• Type of Job

  Full Time (Night Shift)

• Work Location Type

  Work from Office