Appeals Processor III

Ghost RX; United States; On-site; USD 60,000 - 80,000; Full time

Job summary

Ghost RX is seeking an Appeals Processor III (APP III) to join our team remotely. This role focuses on reviewing and processing healthcare appeals related to Medicaid and Medicare coverage decisions. Candidates should have strong experience in the healthcare field, particularly with CMS guidelines and appeal processes.

The ideal applicant will have an Associate’s Degree and over two years of relevant experience, ensuring compliance with state and federal regulations while supporting patients through the appeals process.

Qualifications

• 2+ years of experience in healthcare appeals, medical claims, or Medicaid/Medicare processing.
• Strong knowledge of CMS guidelines and Medicaid/Medicare policies.
• Experience in reviewing medical documentation is essential.

Responsibilities

• Review incoming appeals and medical records for documentation.
• Analyze cases using state and federal regulations.
• Process appeals from start to finish, ensuring compliance.
• Draft determination letters and case summaries for review.

Skills

Healthcare appeals

Medical claims / utilization review

Insurance or Medicaid/Medicare processing

Strong knowledge of CMS guidelines

Experience reviewing medical documentation

Education

Associate’s Degree (Bachelor’s preferred)

Job description

We are seeking a highly skilled Appeals Processor III (APP III) to join our dedicated team in a remote capacity. The Appeals Processor III (APP III) is responsible forreviewing, analyzing, and processing healthcare appealsrelated to Medicaid or Medicare coverage decisions. This role ensures all cases are handled in compliance withfederal/state regulations, CMS guidelines, and contract requirements.

Qualification and Requirements

Requirements

• Associate’s Degree (Bachelor’s preferred)
• 2+ years in:
  • Healthcare appeals
  • Medical claims / utilization review
  • Insurance or Medicaid/Medicare processing
• Strong knowledge of:
  • CMS guidelines
  • Medicaid/Medicare (especially Part C)
  • Experience reviewing medical documentation (clinical roles may require RN)

Responsibilities

Duties

• Review incoming appeals, medical records, and supporting documentation
• Analyze cases using state/federal regulations and CMS guidelines
• Determine if additional documentation is required and request it when needed
• Process appeals from start to finish, including final determinations

Decision Support & Documentation

• Prepare case summaries and ensure files are complete for review
• Draft or support writing determination/decision letters
• Ensure all documentation meets quality and compliance standards