New York Appeals Specialist

Job Summary

Managing a caseload of non-clinical cases, the full-time remote New York Appeals Specialist will be responsible for case development and resolution, ensuring compliance with regulations while investigating and resolving member and provider appeals.

Key Responsibilities

• Develop and resolve non-clinical cases, including claim denials and member complaints, while adhering to regulatory timeframes
• Prepare and submit well-documented appeals in accordance with payer guidelines and identify trends in denials for process improvement
• Stay updated on payer policies and industry regulations to ensure compliance and maximize reimbursement

Required Qualifications

• High School Diploma or GED from an accredited institution
• Minimum of two years of experience in Managed Care Health Insurance Plans
• Experience with appeals for Medicare, Medicaid, Dual enrollment, and commercial plans
• Claims processing experience with coding criteria is preferred
• Demonstrated critical thinking and decision-making competencies