New York Licensed Appeals Specialist

Job Summary

To support the Appeals & Grievances unit, the full-time New York Licensed Appeals Specialist will manage non-clinical case development and resolution for member and provider appeals, ensuring compliance with regulations while working remotely from 8 am to 5 pm or 8:30 am to 5 pm EST.

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 handling 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