Healthcare Appeals Analyst - Regulatory & Compliance

MedPro Group; Springfield (MA); On-site; USD 52,000 - 58,000; Full time

Job summary

Wellfleet, a Berkshire Hathaway company, is seeking an experienced Appeals Analyst to support the Legal team in Springfield, MA. You will review appeals and complaints across all product lines and ensure timely responses within regulatory timeframes.

Responsibilities include analyzing appeals, preparing acknowledgements, gathering documentation, researching guidelines, and collaborating with Compliance to improve processes. Strong communication and medical coding familiarity required.

Qualifications

• Associate’s Degree and 3+ years relevant work experience or equivalent combination of education and experience.
• Detail oriented with strong communication skills.
• Strong organizational skills, including thorough and complete follow-up to all time-sensitive items.
• Excellent written and verbal communication skills.
• Excellent interpersonal skills. Commitment to a team-oriented office environment.
• Internet savvy and proficient with Microsoft Word, Outlook, and Excel.
• Ability to interpret policy language.
• Demonstrated business writing proficiency in accordance with regulatory requirements, internal policies, and claim events.
• Strong aptitude and familiarity with medical coding and medical terminology.
• Strong understanding and familiarity of the different state regulations.
• Must demonstrate excellent written communication skills
• Detail oriented problem solver with good time management skills.

Responsibilities

• Analyze and respond to appeals and Department of Insurance complaints in accordance with policy language, applicable regulatory requirements, and required state and federal timeframes.
• Prepare and send required acknowledgements and correspondence within applicable deadlines.
• Gather, review, and maintain documentation needed to support appeal and complaint responses, including accurate appeal-system documentation.
• Conduct research and analysis using approved guidelines and tools, with consideration of accreditation standards, state and federal regulatory requirements, legal requirements, benefits, COB, ACA, HIPAA Privacy, and claims payment rules.
• Work with Compliance and other departments to monitor requirements, identify trends, and support process improvements.
• Follow up on inquiries, requests, and task assignments through completion.
• Maintain working knowledge of new and existing products, systems, and workflows, including LuminX, Spartacus, and Microsoft Office.
• Communicate with carriers and internal departments as needed, including escalated appeal inquiries.
• Follow management-approved workflows and make independent decisions based on available research and documentation.
• Manage multiple priorities and meet required deadlines.
• Provide back-up support to the Appeals Manager, including regulatory, carrier, and interdepartmental reporting requests; staff onboarding, training, and refresher training; and review of new appeals legislation to support updates to departmental processes and letters.
• Perform other duties as assigned.

Skills

Detail oriented

Communication skills

Organizational skills

Medical coding knowledge

Policy interpretation

Time management

Microsoft Word

Outlook

Excel

Education

Associate’s Degree

Job description

Wellfleet, a Berkshire Hathaway company, is seeking an experienced Appeals Analyst to support the Legal team in Springfield, MA. You will review appeals and complaints across all product lines and ensure timely responses within regulatory timeframes.

Responsibilities include analyzing appeals, preparing acknowledgements, gathering documentation, researching guidelines, and collaborating with Compliance to improve processes. Strong communication and medical coding familiarity required.