Appeals Specialist I

Accountabilities:

• Research and resolve member and provider appeals, disputes, grievances, complaints, and reconsideration requests while meeting applicable internal and regulatory deadlines.

• Investigate claims appeals and grievances using relevant support systems to determine appropriate outcomes.

• Request and review medical records, clinical notes, detailed bills, and other supporting documentation when required.

• Apply established protocols, benefit provisions, contract language, and covered-service guidelines when evaluating cases.

• Research claims processing guidelines, provider contracts, fee schedules, and system configurations to identify and resolve payment issues and determine root causes.

• Prepare concise, accurate appeal summaries, findings, correspondence, and written determinations in accordance with applicable regulatory requirements.

• Communicate resolutions to members, providers, authorized representatives, and external agencies through written and verbal channels.

• Resolve provider reconsideration requests involving claims payments, claim adjustments, and related disputes.

• Monitor and meet departmental productivity and quality standards.

• Identify and communicate relevant trends or recurring issues when requested.

Requirements:

• High school diploma or equivalent.

• At least 2 years of operational managed care experience, ideally within a call center, appeals, claims, or healthcare operations environment.

• Experience with health claims processing, including coordination of benefits, subrogation, and eligibility requirements.

• Familiarity with Medicare and Medicaid claims denials, appeals processing, and applicable regulatory requirements.

• Strong understanding of healthcare claims workflows, benefits, provider contracts, and payment processes.

• Excellent written and verbal communication skills, with the ability to explain complex information clearly and professionally.

• Strong research, analytical, and problem-solving abilities with exceptional attention to detail.

• Ability to manage multiple cases while consistently meeting production, quality, and regulatory deadlines.

• Ability to work independently while following established procedures, protocols, and compliance requirements.

• Strong organizational skills and a commitment to accuracy, confidentiality, and member-focused service.

Benefits:

• $21.92/hour on W-2, all-inclusive.

• Fully remote work arrangement.

• Full-time contract position initially scheduled for 14 weeks, with potential for extension or conversion.

• Monday–Friday schedule, 8:00 AM–4:30 PM.

• Four medical insurance options for eligible full-time employees working at least 30 hours per week.

• Dental and vision insurance.

• 401(k) contributions.

• Critical illness insurance.

• Voluntary permanent life insurance.

• Accident insurance.

• Additional employee perks and benefits.