Appeals Specialist

Employer Industry

Healthcare Services

• Salary up to $37.30 per hour
• Bonus target of 5%
• Generous benefits including medical, dental, and vision coverage
• Opportunity for career advancement and professional growth within a well-established organization
• Flexibility to work from home within designated states
• Supportive and collaborative work environment focused on employee well-being

• Validate intake determinations for appeals and document relevant information in appropriate systems
• Review claim coding, processing history, and provider contracts to formulate appeal recommendations
• Make non-clinical appeal determinations and communicate decisions to members and providers
• Oversee the setup of appeals for external review organizations and coordinate necessary documentation
• Track appeals and compile reports on trends, decisions, and process improvements

• High school diploma or GED required
• Minimum 4 years of experience in Customer Service, Claims, or Clinical Services, or equivalent combination of education and work experience
• Excellent verbal and written communication skills
• Intermediate computer skills, including Microsoft Word, Excel, and Outlook
• Knowledge of medical terminology and claims processing operations

• Coding Certification (CPC, CCS, or similar)
• Experience with AI tools and technologies to enhance productivity
• Demonstrated initiative and analytical ability in problem-solving
• Ability to prioritize work effectively to meet deadlines
• Experience working collaboratively in a team environment

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