Medicare Appeals & Policy Resolution Specialist

Jobtailor; Harrisburg (Dauphin County); On-site; USD 52,000 - 76,000; Full time

Job summary

Jobtailor in Harrisburg, PA seeks a detail‑oriented Appeals Specialist to review policy issues, analyze CMS guidance, and manage Medicare Part C and Part D appeals. The role requires interpreting complex regulations, coordinating with PBMs, and preparing cases for QIO/IRE.

Strong communication and independent work style are essential. This position emphasizes regulatory compliance, data analysis, and cross‑functional collaboration with Marketing, Legal, and provider groups.

Qualifications

• Minimum of two years customer service or correspondence experience.
• Ability to interpret detailed policies and procedures.
• HIPAA privacy knowledge and compliance experience.
• Strong verbal and written communication skills.
• Ability to work independently and adapt to changing assignments.
• Occasional travel may be required.

Responsibilities

• Identify, review, and analyze policy and procedure issues and recommend solutions.
• Ensure compliance with organizational, CMS, and regulatory requirements.
• Research and analyze redetermination, reconsideration, and provider appeals.
• Interpret policies and CMS/HHS guidance to determine actions.
• Use PC systems, imaging technology, and PBM system to obtain case information.
• Handle Medicare Part C and Part D grievances and related appeals.
• Prepare cases for submission to QIO and IRE; attend hearings when required.
• Resolve routine and complex appeals involving benefits, claims, enrollment, and payments.

Skills

Medicare Compliance

Appeals Processing

Customer Service

Analytical Skills

Effective Communication

Education

High School diploma

Bachelor's degree in business administration or health care administration

Tools

Facets System

PBM System

Microsoft Word

Microsoft Excel

PowerPoint

Imaging Technology

Secure IT

Job description

Jobtailor in Harrisburg, PA seeks a detail‑oriented Appeals Specialist to review policy issues, analyze CMS guidance, and manage Medicare Part C and Part D appeals. The role requires interpreting complex regulations, coordinating with PBMs, and preparing cases for QIO/IRE.

Strong communication and independent work style are essential. This position emphasizes regulatory compliance, data analysis, and cross‑functional collaboration with Marketing, Legal, and provider groups.