Appeals Specialist

Job Summary

Appeals Specialist is a full-time position responsible for managing non-clinical case development and resolution of member and provider appeals while ensuring compliance with regulations.

Key Responsibilities

• Manage case development and resolution for non-clinical cases, including claim denials and member complaints
• Prepare and submit well-documented appeals in accordance with payer guidelines
• Identify trends in denials and provide feedback for process improvement

Required Qualifications

• High School Diploma or GED from an accredited institution
• Minimum of two years of work experience in Managed Care Health Insurance Plan
• Experience with appeals for Medicare, Medicaid, Dual enrollment, and commercial plans
• Claims processing experience with coding criteria is preferred
• Bachelor's degree or relevant work experience is preferred