Appeals Specialist II

Health Care Service; United States; Remote; USD 26,000 - 47,000; Full time

Job summary

Health Care Service Corporation is seeking a skilled Appeals Specialist to process and adjudicate complex non-utilization appeals and manage related regulatory compliance under federal, state, and NCQA requirements.

The role involves responding to member inquiries by phone or written correspondence, training junior staff, and coordinating references materials to handle high volumes efficiently. Remote work within the continental US is available.

Qualifications

• 3 years' experience in a customer service role or in a health insurance or medical environment.
• Knowledge of medical terminology including coding.
• Experience and skills to analyze and assist customers based on federal, state, and NCQA guidelines.

Responsibilities

• Process and adjudicate complex non-utilization appeals.
• Manage appeals according to federal, state, and NCQA requirements.
• Respond to inquiries by phone, in person, or in writing.
• May train and mentor less experienced Appeals Specialists.

Skills

Customer service

Medical terminology

Communication skills

Education

High School Degree or GED

Tools

Claims payment system

Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Job Summary

Under Supervision, This Position Is Responsible For Processing And Adjudicating Complex Non-Utilization. Management Appeals According To The Appropriate Federal, State, And Ncqa Requirements And Regulations; And Responding, By Phone, In Person, Or In Writing, To All Inquiries Involving Member*S Requests For Appeals. May Train And Mentor Less Experienced Appeals Specialists.

JOB REQUIREMENTS:

• High School Degree or GED.
• 3 years' experience in a customer service role OR in a health insurance or medical environment.
• Knowledge of medical terminology to include coding.
• Experience and skills to analyze and assist customer based on knowledge of federal, state, and NCQA guidelines.
• Experience and skills to organize tasks and accommodate large volume of reference materials.
• Experience and skills to understand fine details of customer complaint issues.
• Verbal and written communication skills.

PREFERRED JOB REQUIREMENTS:

• Claims experience.
• 2-year experience processing claims and utilizing a claims payment system.
• Bilingual English/Spanish.

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards .

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii .

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. We are a drug-free and smoke-free workplace. Employment may be contingent upon successful completion of drug screening in accordance with applicable law.

Base Pay Range

$19.13 - $34.17

Exact compensation may vary based on skills, experience, and location.