Appeals Specialist I

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for an Appeals Specialist I based in the United States. This fully remote role offers the opportunity to support members and providers by researching, evaluating, and resolving healthcare appeals and complaints. You’ll investigate claims, grievances, disputes, and reconsideration requests while ensuring decisions are accurate, well documented, and timely. The position requires a strong understanding of healthcare claims, benefits, contracts, and applicable Medicare and Medicaid requirements. You’ll work with medical records, claims systems, provider information, and regulatory guidelines to determine appropriate outcomes. Clear communication will be essential as you explain resolutions to members, providers, authorized representatives, and external agencies. You’ll also help identify root causes of payment issues and contribute to accurate, compliant written correspondence. This is a structured, detail-oriented opportunity for a healthcare operations professional who values accuracy, accountability, and member-focused service.

Research and resolve member and provider appeals, disputes, grievances, complaints, and reconsideration requests while meeting applicable internal and regulatory deadlines. Investigate claims appeals and grievances using relevant support systems to determine appropriate outcomes. Request and review medical records, clinical notes, detailed bills, and other supporting documentation when required. Apply established protocols, benefit provisions, contract language, and covered-service guidelines when evaluating cases. Research claims processing guidelines, provider contracts, fee schedules, and system configurations to identify and resolve payment issues and determine root causes. Prepare concise, accurate appeal summaries, findings, correspondence, and written determinations in accordance with applicable regulatory requirements. Communicate resolutions to members, providers, authorized representatives, and external agencies through written and verbal channels. Resolve provider reconsideration requests involving claims payments, claim adjustments, and related disputes. Monitor and meet departmental productivity and quality standards. Identify and communicate relevant trends or recurring issues when requested. Requirements: High school diploma or equivalent. At least 2 years of operational managed care experience, ideally within a call center, appeals, claims, or healthcare operations environment. Experience with health claims processing, including coordination of benefits, subrogation, and eligibility requirements. Familiarity with Medicare and Medicaid claims denials, appeals processing, and applicable regulatory requirements. Strong understanding of healthcare claims workflows, benefits, provider contracts, and payment processes. Excellent written and verbal communication skills, with the ability to explain complex information clearly and professionally. Strong research, analytical, and problem-solving abilities with exceptional attention to detail. Ability to manage multiple cases while consistently meeting production, quality, and regulatory deadlines. Ability to work independently while following established procedures, protocols, and compliance requirements. Strong organizational skills and a commitment to accuracy, confidentiality, and member-focused service. Benefits: $21.92/hour on W-2, all-inclusive. Fully remote work arrangement. Full-time contract position initially scheduled for 14 weeks, with potential for extension or conversion. Monday–Friday schedule, 8:00 AM–4:30 PM. Four medical insurance options for eligible full-time employees working at least 30 hours per week. Dental and vision insurance. 401(k) contributions. Critical illness insurance. Voluntary permanent life insurance. Accident insurance. Additional employee perks and benefits.