Remote Healthcare 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

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.