Appeals Specialist

Jobgether; United States; Remote; USD 32,000 - 41,000; Full time

Benefits offered by this job

Healthcare coverage

Paid time off

Monthly stipend for mobile/internet

Stock options

Bonus eligibility

401(k) retirement plan

Fully remote within the United States

Parental leave

Job summary

Jobgether partners with a company seeking an Appeals Specialist based in the United States. The role focuses on managing healthcare-related appeals from receipt to resolution, coordinating with Clinical teams, Medical Directors, UM, and Claims to ensure compliant, timely decisions.

You will communicate with members and providers, maintain robust case documentation, and contribute to process improvements while upholding policies and regulatory requirements.

Qualifications

• Bachelor's degree in Healthcare, Conflict Resolution, or related field or equivalent experience
• Strong computer skills and ability to manage electronic records
• Excellent analytical and investigative abilities to evaluate complex information
• Attention to detail and high data integrity when handling sensitive information
• Excellent written and verbal communication skills to explain policies clearly
• Strong interpersonal and customer service skills to engage with members and providers
• Ability to work with cross-functional teams and manage multiple cases

Responsibilities

• Manage the receipt, investigation, review, and resolution of appeals from members, providers, and authorized representatives.
• Ensure timely processing within established timelines and regulatory requirements.
• Conduct detailed investigations and gather information to support decisions.
• Coordinate with Clinical, Medical Directors, UM, and Claims teams for case reviews.
• Collaborate with external partners and vendors as needed.
• Communicate with members and providers with clear explanations and updates.
• Maintain accurate records of communications, investigations, and outcomes in internal systems.
• Develop knowledge of policies and guidelines to provide accurate information to stakeholders.
• Perform data entry and CMS reporting requirements across multiple systems.
• Identify discrepancies to maintain data integrity and compliance.
• Contribute to Appeals Operations and Provider Escalations through collaboration and process improvements.

Skills

Analytical thinking

Written communication

Verbal communication

Interpersonal skills

Time management

Collaboration

Education

Bachelor's degree in Healthcare or related field

Tools

CMS systems

Job description

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 based in the United States.

As an Appeals Specialist, you will play an essential role in managing and resolving healthcare-related appeals while ensuring fair, accurate, and timely decisions for members and providers. You will oversee the full appeals process, from initial receipt and investigation to case resolution, working with internal clinical teams, medical directors, utilization management, and claims departments. Through careful research, effective communication, and thorough documentation, you will help ensure that every appeal is handled in accordance with applicable policies and regulatory requirements. You will also serve as an important point of contact for members, healthcare providers, and other stakeholders, providing clear guidance throughout the review process. This role offers the opportunity to contribute directly to healthcare quality, operational excellence, and positive member experiences. You will join a collaborative, mission-driven environment that values accuracy, accountability, and compassionate service.

Accountabilities

• Manage the receipt, investigation, review, and resolution of appeals submitted by health plan members, contracted and non-contracted providers, and authorized representatives.
• Ensure all appeals are processed accurately, efficiently, and within established timelines and applicable regulatory requirements.
• Conduct detailed case investigations, gathering relevant information and documentation to support appropriate and well-informed appeal decisions.
• Coordinate with internal departments, including Clinical, Medical Directors, Utilization Management (UM), and Claims teams, to obtain necessary information and ensure comprehensive case reviews.
• Collaborate with managers, external vendors, and other stakeholders throughout the investigation and resolution process, including preparing cases for internal or external review when required.
• Communicate with members, healthcare providers, and their representatives through written correspondence and telephone calls, providing clear explanations and appropriate updates.
• Maintain accurate records of all communications, investigations, decisions, and case outcomes in accordance with internal procedures and documentation standards.
• Develop and maintain a thorough understanding of healthcare products, policies, procedures, and appeal guidelines to provide accurate and consistent information to internal and external stakeholders.
• Complete required data entry and documentation across multiple systems, ensuring accuracy and completeness of information, including all applicable Centers for Medicare & Medicaid Services (CMS) reporting requirements.
• Identify and address discrepancies or missing information to maintain data integrity and support compliant appeals operations.
• Contribute to the effectiveness of the Appeals Operations and Provider Escalations teams through strong collaboration, problem-solving, and continuous process improvement.

Requirements

• Bachelor's degree in Healthcare, Conflict Resolution, or a related field, or equivalent relevant professional experience.
• Strong computer skills, with the ability to navigate multiple systems, manage electronic records, and perform accurate data entry.
• Excellent analytical and investigative abilities, with the capacity to evaluate complex information, identify discrepancies, and support sound decision-making.
• Exceptional attention to detail, particularly when handling sensitive information, maintaining case documentation, and ensuring data integrity.
• Excellent written and verbal communication skills, with the ability to explain policies, procedures, and appeal decisions clearly and professionally.
• Strong interpersonal and customer service skills, with the ability to communicate effectively and empathetically with members, providers, and internal stakeholders.
• Demonstrated problem-solving and conflict-resolution abilities, particularly when managing complex or sensitive appeal situations.
• Strong organizational and time management skills, with the ability to manage multiple cases, prioritize competing deadlines, and meet established service requirements.
• Ability to work collaboratively with cross-functional teams, including clinical professionals, medical directors, claims specialists, and external partners.
• High level of professionalism, accountability, and discretion when handling confidential healthcare and member information.
• Working knowledge of healthcare insurance products, policies, procedures, and claims processes is highly desirable.
• Previous experience in healthcare appeals, insurance operations, provider relations, or case investigation is an advantage.
• Ability to adapt to changing priorities while maintaining accuracy, compliance, and high-quality service.

Benefits

• Competitive hourly compensation: $23-$30 per hour, depending on qualifications, relevant experience, education, specialized skills, and work location.
• Employer-sponsored healthcare coverage, including medical, dental, and vision insurance, with low or no employee premiums.
• Generous paid time off.
• Monthly mobile phone or internet stipend of $100.
• Stock options available to employees.
• Bonus eligibility for applicable positions.
• Parental leave program.
• 401(k) retirement savings plan.
• Fully remote working arrangement within the United States.
• Opportunity to contribute to meaningful healthcare initiatives focused on improving the health and well-being of older adults.
• Collaborative and supportive working environment that values diversity, inclusion, and different professional perspectives.
• Opportunities to work alongside experienced healthcare, clinical, and operational professionals.