Appeals Specialist I

Job Title: Appeals Specialist I
Location: Houston, TX (Remote)
Candidates must reside in one of the following 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)
 
Schedule:

• 100% Remote
• Monday–Friday, 8:00 AM – 4:30 PM (local timezone)

 
Job Summary:

• Responsible for reviewing and resolving member and provider complaints and communicating resolutions in accordance with standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).
• Conducts research on claims, appeals, grievances, and complaints to ensure regulatory timelines and internal standards are met.

 
Day-to-Day Duties:

• Research member complaints, update system records, and resolve complaints within designated timeframes.
• Review claims appeals and grievances using support systems to determine outcomes.
• Request and review medical records, notes, and detailed bills to formulate conclusions per protocol and business requirements.
• Ensure timeliness and appropriateness of responses according to state, federal, and organizational guidelines.
• Apply contract language, benefits, and coverage review to resolve complaints.
• Contact members/providers through written and verbal communication.
• Prepare appeal summaries, correspondence, and documentation of findings, including trends if requested.
• Compose all correspondence and appeal/grievance information accurately and concisely, in compliance with regulatory requirements.
• Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine root causes of payment errors.
• Resolve and prepare written responses to provider reconsideration requests related to claims payment or adjustments.

 
Required Education:

• High School Diploma or equivalency

 
Required Experience:

• Minimum 2 years of operational managed care experience (call center, appeals, or claims environment).
• Health claims processing experience, including coordination of benefits, subrogation, and eligibility criteria.
• Familiarity with Medicaid and Medicare claims denials, appeals processing, and regulatory guidelines for appeals and denials.
• Strong verbal and written communication skills.

 
Key Skills & Abilities:

• Comprehensive research and resolution of appeals, disputes, grievances, and complaints.
• Strong knowledge of claims processing, contract language, and provider agreements.
• Ability to meet production standards and deadlines.
• Excellent written and verbal communication skills.
• Attention to detail and adherence to regulatory compliance.