Remote Appeals Specialist for Medicare/Medicaid

Healthfirst; New York (NY); Hybrid; USD 51,000 - 80,000; Full time

Benefits offered by this job

Health insurance

Dental and vision coverage

401k plan

Job summary

Healthfirst is seeking an Appeals Specialist for a 100% remote role, Monday through Friday, 8am-5pm EST or 8:30am-5pm EST. You will manage non-clinical case development and ensure compliance with Federal and State regulations while handling a personal caseload of member and provider appeals.

Responsibilities include researching issues, interpreting payer policies, and resolving denials within regulatory timeframes. Strong attention to detail and the ability to work independently are essential.

Qualifications

• Minimum of two (2) years of work experience in Managed Care Health Insurance Plan.
• Experience with appeals for Medicare, Medicaid, Dual enrollment and commercial plans end to end.
• HS Diploma or GED from an accredited institution; Bachelor’s degree preferred.
• Claims processing experience with coding criteria is preferred.

Responsibilities

• Research issues and frame decisions.
• Interpret regulations and reference internal health plans’ policies.
• Resolve cases and make critical decisions.
• Edit and finalize resolution letters within regulatory timeframes.
• Identify patterns or trends in denials for process improvement.
• Prepare and submit well documented appeals per payer guidelines.

Skills

Critical thinking

Detail oriented

Time management

Education

HS Diploma or GED

Bachelor’s degree or relevant work experience

Job description

Healthfirst is seeking an Appeals Specialist for a 100% remote role, Monday through Friday, 8am-5pm EST or 8:30am-5pm EST. You will manage non-clinical case development and ensure compliance with Federal and State regulations while handling a personal caseload of member and provider appeals.

Responsibilities include researching issues, interpreting payer policies, and resolving denials within regulatory timeframes. Strong attention to detail and the ability to work independently are essential.