Appeals Specialist
Core
Manage and resolve healthcare-related appeals for members and providers, ensuring fair and timely decisions in compliance with regulatory requirements.
Role type
Healthcare appeals operations specialist
Builds
Resolved appeal cases and compliant documentation for health plans
Domain
Healthcare insurance and regulatory compliance
Required skills
Case investigation, regulatory compliance, data entry, stakeholder communication, conflict resolution, policy interpretation, documentation management, time management, cross-functional collaboration, attention to detail
Preferred skills
Healthcare insurance knowledge, provider relations experience, CMS reporting familiarity
Responsibilities
Manage receipt, investigation, review, and resolution of appeals; Conduct detailed case investigations; Coordinate with internal departments (Clinical, UM, Claims); Communicate with members and providers; Maintain accurate records; Complete CMS reporting requirements; Identify and address data discrepancies
Seniority
Individual contributor, operational level