Appeals Examiner- Healthcare

Wipro; Tampa (FL); On-site; USD 40,000 - 44,000; Full time

Benefits offered by this job

Full range of medical and dental benefits

Disability insurance

Paid time off, including sick leave

Job summary

A healthcare service provider is looking for an Appeals Examiner to manage provider reconsiderations and appeals. This role requires strong problem-solving skills and a commitment to compliance. The ideal candidate will coordinate appeals processes, document outcomes meticulously, and collaborate with internal teams for resolution. Applicants should have a high school diploma, with further education preferred, and familiarity with healthcare coding systems is beneficial. The expected salary ranges from $40,000 to $44,000 annually, with a full benefits package provided.

Qualifications

• High school diploma or GED equivalent is required.
• Proven problem-solving abilities required.
• Working knowledge of healthcare coding systems preferred.

Responsibilities

• Coordinate review and resolution of member appeals.
• Document all case actions for auditing.
• Collaborate with internal teams for case resolution.
• Interpret Summary Plan Documents for appeal validity.
• Ensure compliance with HIPAA regulations.

Skills

Problem-solving abilities

Interpersonal communication

Time management

Education

High School diploma or GED

Certifications in healthcare administration

Tools

Microsoft Office Suite

Claims management software

Job description

The Appeals Examiner plays a critical role within the team by managing and processing provider reconsiderations and appeals with utmost accuracy and compliance. The examiner collaborates with cross‑functional teams to deliver timely resolutions and supports ongoing improvements in operational workflows.

This role requires dedication to upholding the integrity of benefit plan interpretation and a commitment to high‑quality case management. The Appeals Examiner will be integral in fostering positive relationships with providers and members by ensuring that each appeal is handled with attention to detail and professionalism.

As a part of the team, you will contribute to a dynamic environment focused on delivering excellence in healthcare service operations while developing your expertise in benefit administration and regulatory compliance.

Role Purpose

The Appeals Examiner plays a critical role within the team by managing and processing provider reconsiderations and appeals with utmost accuracy and compliance. The examiner collaborates with cross‑functional teams to deliver timely resolutions and supports ongoing improvements in operational workflows.

Essential Job Functions and Duties

• Coordinate comprehensive review and resolution of member appeals and provider disputes, ensuring compliance with Department of Labor regulations and client‑specific service level agreements (SLAs).
• Meticulously document all case actions and outcomes to maintain accurate records for auditing and quality assurance purposes.
• Collaborate closely with internal teams, including medical review and adjustment departments, to facilitate escalations and timely resolution of complex cases.
• Utilize problem‑solving skills to interpret Summary Plan Documents, enabling accurate determination of appeal validity and appropriate responses.
• Ensure strict adherence to HIPAA and privacy guidelines with regard to the confidential handling and release of member and provider information.
• Engage in ongoing communication with providers, members, and stakeholders to clearly convey appeal decisions and next steps.
• Assist in research and response to member complaints, working alongside both internal departments and external contacts as necessary.
• Support continuous improvement by recommending process enhancements and sharing insights during team meetings and training sessions.
• Perform additional duties as assigned to contribute to the overall success of the appeals and grievance department.

Qualification Requirements

• High School diploma or GED equivalent required; additional education or certifications related to healthcare administration or insurance processes are a plus.
• Proven problem‑solving abilities with a focus on interpreting benefit plans and related documentation accurately.
• Working knowledge or familiarity with healthcare coding systems such as CPT and ICD‑9/ICD‑10, as well as medical terminology, strongly preferred but not mandatory.
• Ability to work effectively with minimal supervision while managing multiple priorities in a fast‑paced environment.
• Proficiency in standard computer applications (Microsoft Office Suite) and experience with specialized claims or case management software is advantageous.
• Demonstrated average to above‑average typing skills to ensure efficient data entry and documentation.
• Excellent interpersonal and communication skills, enabling professional interaction with members, providers, and team members.
• A strong commitment to confidentiality, accuracy, and compliance with regulatory standards.

Compensation and Benefits

The expected compensation for this role ranges from $40,000 to $44,000 per year. Final compensation will depend on various factors, including your geographical location, minimum wage obligations, skills, and relevant experience. The role is also eligible for Wipro’s standard benefits, including a full range of medical and dental benefits options, disability insurance, paid time off (inclusive of sick leave), and other paid and unpaid leave options.

Applicants are advised that employment in some roles may be conditioned on successful completion of a post‑offer drug screening, subject to applicable state law.

EEO Statement

Wipro provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. Applications from veterans and people with disabilities are explicitly welcome.