Appeals Specialist I

Job Title: Appeals Specialist I
Location: Remote — Candidates must reside in one of the preferred 15 states: Client, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater NYC), OH, TX, UT, WA (outside greater Seattle), WI.
Duration: 3+ Months (Possibility of Extension)

Pay Range: $21.29/hr. on W2
 
Shift: Work schedule aligns with candidate’s local timezone, Monday to Friday, 8:00 AM – 4:30 PM.
 
Job Summary:
Responsible for researching, reviewing, and resolving member and provider complaints in compliance with Centers for Medicare and Medicaid standards. This role requires detailed investigation of appeals, disputes, grievances, and claims to ensure timely and accurate resolutions while maintaining regulatory compliance.
 
Key Responsibilities:

• Conduct comprehensive research and resolution of appeals, disputes, grievances, and complaints from members, providers, and external agencies.
• Ensure all investigations and responses meet internal and regulatory timelines.
• Analyze claims appeals and grievances using internal systems to determine appropriate outcomes.
• Request and review medical records, provider notes, and detailed billing documentation as necessary.
• Apply contract language, benefit coverage, and policy guidelines to assess claims and appeals.
• Maintain consistent communication with members and providers via written and verbal channels regarding complaint resolution.
• Prepare appeal summaries, official correspondence, and document findings clearly and accurately per regulatory requirements.
• Research provider contracts, fee schedules, and claim processing guidelines to identify root causes of payment errors.
• Respond to provider reconsideration requests related to claims payments and adjustments.
• Meet or exceed departmental production standards.

 
Required Qualifications:

• High School Diploma or equivalent.
• Minimum 2 years operational experience in managed care, including call center, appeals, or claims processing environments.
• Strong background in health claims processing, including coordination of benefits, subrogation, and eligibility criteria.
• Familiarity with Medicaid and Medicare claims denials, appeals processing, and relevant regulatory guidelines.
• Excellent verbal and written communication skills.