Claims & Appeals Specialist

Job Summary

Detail-oriented and organized, the full-time Claims & Appeals Specialist will review and process healthcare claims, manage appeals and grievances, and ensure compliance with regulatory requirements while working remotely.

Key Responsibilities

• Review, validate, and process medical, behavioral health, and pharmacy claims in accordance with health plan policies
• Receive, review, and process member and provider appeals and grievances, coordinating with internal teams as necessary
• Perform data entry, record maintenance, and quality validation activities, ensuring confidentiality of Protected Health Information (PHI)

Required Qualifications

• High School Diploma or GED required; Associate's or Bachelor's degree preferred
• Minimum of 2 years of experience in US Healthcare Back Office Operations
• Experience in healthcare claims processing and Appeals & Grievances
• Knowledge of commercial, Medicare, and/or Medicaid health plans
• Familiarity with CPT, ICD-10-CM, HCPCS, and healthcare documentation