State Licensed Appeals Specialist

Job Summary

Reviewing, analyzing, and resolving insurance denials, the full-time State Licensed Appeals Specialist will ensure accurate reimbursement and regulatory compliance while collaborating with internal teams and providing feedback on denial trends in a remote work environment.

Key responsibilities

• Files medical necessity and level of care appeals using relevant guidelines
• Monitors clinical appeal processes for trends and provides guidance to related departments
• Tracks and manages clinical denials, maintaining documentation and ensuring compliance with policies

Required qualifications

• Associate Degree in Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy required
• 3-5 years of experience in clinical operations in a relevant field required
• 1-3 years of experience in claims processing, healthcare billing, or revenue cycle management preferred
• 1-3 years of experience in utilization review and/or case management preferred
• State Licensure as a Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist required