Appeals Specialist
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
MedReview Appeals Specialist resolving facility payment, reimbursement, and administrative appeals. Reviewing cases, determining policy-based decisions, and coordinating clinical escalations for healthcare payment integrity.
Responsibilities:
- Triage administrative appeals to validate appropriateness for review and determine workflow
- Route appeals appropriately when new information warrants clinical review
- Process non-clinical facility appeals involving payment disputes, reimbursement amounts, contract interpretation, and processing errors
- Analyze payment history and contracts in client applications
- Process clinical appeals when no new clinical information is submitted
- Determine appeal decisions according to client and/or organizational policies
- Provide clear, thorough, and accurate appeal responses
- Coordinate and communicate with Clinical Review teams when new clinical information is received or escalation is required
- Communicate with stakeholders regarding emergent matters or trends
Requirements:
- Associate degree (healthcare field preferred) or an equivalent combination of education and relevant work experience
- 1 year of experience working in healthcare claims, appeals, billing, or revenue cycle
- Experience handling administrative review of clinical appeals
- Strong professional judgment and escalation awareness
- Ability to analyze case details and make timely, sound decisions
- Ability to quickly learn and navigate new systems and platforms
- Basic understanding of claims adjudication processes and terminology
- Excellent written and verbal communication skills
- Ability to manage tasks and prioritize work effectively
- High attention to detail and document accuracy
- Proficiency in MS Office applications, including Outlook, Excel, and Word
- Ability to multitask, manage a high-volume caseload, and meet strict time-sensitive deadlines
- Ability to work independently
- Patience and ability to remain calm under pressure amid frequent interruptions
- High-speed internet (100 Mbps per person recommended) with secured WIFI
- Dedicated workspace with minimal interruptions to protect PHI and HIPAA information
- Ability to sit and use a computer keyboard for extended periods
Benefits:
- Remote work
- High-speed internet requirement with secured WIFI
- Dedicated workspace with minimal interruptions to protect PHI and HIPAA information
Similar Jobs
Brand Licensing Specialist
Brand Licensing Specialist managing licensees and licensed product development for Scouting America, a youth-serving organization. Driving brand-compliant sales, royalties, retail distribution, and new partnerships.
Port Captain
Port Captain overseeing vessel crews, compliance, scheduling, and operations for Curtin Maritime’s marine construction and transportation projects. Managing maritime projects from bid award through completion, including voyage planning, audits, training, and fleet coordination.
Care Specialist, Overnight Hours
Care Specialist delivering overnight chat and phone support for Empathy’s family-care platform. Researching resources, creating Care Plans, and guiding families through difficult life events.
EDI Specialist – Field
Field EDI Specialist supporting healthcare integrations, EMR connectivity, and client training for Labcorp in South Carolina. Liaising with sales and IT to implement laboratory interface solutions.
Patient Engagement Specialist
Patient Engagement Specialist supporting Cadence’s remote chronic-care monitoring program. Conducting outreach, scheduling appointments, improving adherence, and re-engaging patients between clinical visits.
Wildlife Biologist – Field Focused
Field Wildlife Biologist conducting California wildlife, aquatic-resource, and construction-compliance surveys for AECOM broadband infrastructure projects. Supporting environmental permitting and contractor training across the Central Valley.
Wildlife Biologist – Field Focused
Field Wildlife Biologist conducting biological surveys and construction monitoring for AECOM’s California broadband infrastructure projects. Supporting environmental compliance across the Central Valley.
AgriTech Co-Founder, CPO
AgriTech entrepreneur owning and scaling a startup with EWOR’s support. Building product-market fit, hiring teams, and securing multi-million-euro funding.
Co-Founder / CPTO
GovTech entrepreneur owning and scaling a startup with EWOR. Receiving founder coaching, hiring support, product-market-fit guidance, and funding assistance.
Co-Founder, CSO
Remote AgriTech co-founder owning and scaling a startup with EWOR’s support. Building product-market fit, teams, sales or marketing engines, and multimillion-euro funding readiness.
Co-Founder / CPTO
Remote Applied AI co-founder owning and scaling a startup with EWOR GmbH. Accessing unicorn-founder coaching, hiring support, distribution guidance, and funding assistance.
HealthTech Co-Founder, CCO
HealthTech co-founder owning and scaling a startup with EWOR GmbH. Receiving unicorn-founder coaching, hiring support, and funding assistance to reach product-market fit and €100M+ revenue.
Co-Founder, CPTO
DeepTech co-founder owning and scaling a startup with EWOR, a startup venture-building platform. Receiving founder coaching, hiring support, product-market-fit guidance, and fundraising assistance.
Order Processing Specialist
Order Processing Specialist supporting a structured-literacy solutions provider’s customers and internal systems. Recording purchase-order transactions, handling inquiries, and resolving issues across departments.
Worker Engagement Specialist
Worker Engagement Specialist deploying digital worker voice programs for African suppliers. Training management, engaging workers, and managing grievances to improve labor conditions and supply-chain accountability.
Local Contact Person for Pharmacovigilance – Freelance
Freelance LCPPV coordinating local pharmacovigilance compliance and safety activities. Supporting post-marketing programs for Allucent’s biopharmaceutical clients.
Dutch Speaking Automotive Technical Specialist
Automotive technical specialist supporting European dealers with vehicle diagnostics and repair guidance. MSX delivers technology-enabled mobility solutions for vehicle manufacturers and retailers.
Asesor Contactados Migraciones, Full Time
Asesor remoto contactando clientes para fidelización y migración de planes prepago a postpago. Partner Service impulsa servicios de telecomunicaciones en Perú mediante ventas telefónicas.
Asesor de portabilidad, desde casa
Asesor de portabilidad remoto contactando clientes postpago y promoviendo su cambio a Claro. Sin experiencia; turnos full time o semi full time, con comisiones y bono.
Cruise & Resort Booking Specialist
Independent remote travel agent designing customized resort, cruise, and vacation packages. Booking reservations, recommending upgrades, and serving travelers with training and mentorship.