Appeals Specialist I

Position Summary

This role involves remotely handling appeals, grievances, disputes, and complaints from members and providers within the managed care environment. The specialist researches and evaluates claims, medical documentation, authorizations, and benefit details to ensure accurate adjudication of cases in line with regulatory standards and internal policies.

Responsibilities

• Conduct thorough investigations of appeals and grievances from both members and providers.
• Examine claims, clinical records, bills, authorization documents, and benefits information to make informed case decisions.
• Apply relevant contracts, policies, regulations, and procedures to determine case outcomes appropriately.
• Research claims-processing guidelines, provider agreements, fee schedules, and system configurations to assist with case resolution.
• Identify root causes of payment errors and prepare detailed responses to reconsideration and adjustment requests.
• Draft clear appeal summaries, acknowledgment notices, determination letters, and resolution correspondence.
• Communicate effectively with members, providers, authorized representatives, and external agencies regarding case results.
• Maintain comprehensive and accurate records in case management systems.
• Ensure adherence to regulatory deadlines and internal turnaround time requirements by monitoring case progress.
• Apply contract language, eligibility rules, covered service criteria, and benefit provisions accurately.
• Meet departmental productivity, quality, and performance goals consistently.
• Identify trends in case types, quality issues, and opportunities for process improvement and escalate when necessary.
• Handle protected health information in compliance with privacy and security policies.

Requirements

• Minimum of a high school diploma or equivalent.
• At least two years of experience in managed care operations, specifically in appeals, grievances, claims processing, or call center roles.
• Direct experience with appeals and grievance procedures.
• Familiarity with health claims processing systems.
• Understanding Medicare and Medicaid plans, including claims denial and appeal mechanisms.
• Knowledge of regulatory criteria impacting appeals, grievances, complaints, and denials.
• Ability to review coordination of benefits, subrogation matters, and eligibility verification.
• Strong written and verbal communication proficiency.
• Detail-oriented research skills and aptitude for thorough documentation and correspondence preparation.
• Capacity to manage a high volume of cases while meeting productivity standards and strict regulatory timelines.

Preferred Qualifications

• Experience interpreting provider contracts, fee schedules, and claims-payment setups.
• Background in preparing written responses to provider reconsideration and adjustment requests.
• Knowledge of managed care case management or claims systems related to appeals.
• Skill in detecting operational patterns and suggesting enhancements for process efficiency.

Additional Details

• Location: Remote within the United States.
• Contract length: 3 months.
• Work schedule: Monday through Friday, 8:30 AM to 5:00 PM local time, with flexible start and end times.
• Hours: 40 per week.
• Position type: W2 employment only; C2C, 1099, or visa sponsorship not considered.
• Compensation: $18.90 to $21.00 per hour.