Appeals Review Specialist

Job Summary

Working remotely on a full-time salaried basis, the Appeals Review Specialist will review claims for accuracy, respond to inquiries from members and providers, and ensure compliance with regulatory standards while maintaining quality assurance in claims processing.

Key responsibilities

• Verify claim accuracy against medical records and review for fraud and abuse
• Respond to member and provider inquiries regarding claim denials and provide denial explanations
• Participate in quality assurance initiatives and collaborate with cross-departmental teams to improve processes

Required qualifications

• High school diploma or equivalent
• Minimum of two years of experience in healthcare claims examining or related work
• Proficient in Microsoft Office and possess strong typing skills
• Ability to maintain neutrality and confidentiality in all interactions
• Demonstrated organizational and self-motivation skills