Appeals Specialist I – Managed Care Organization
Location: 100% Remote – Candidates must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY, OH, TX, UT, WA, or WI
Pay: $22/hour
Assignment Type: Temp-to-Perm
Work Schedule: Monday – Friday, Standard Business Hours (Local Time)
Benefits: Medical, dental, vision, and 401(k) with 50% employer contribution towards premiums
About the Organization
Join a mission-driven managed care organization serving Medicaid and Medicare members nationwide. This organization is known for delivering high-quality, community-based healthcare solutions and advocating for underserved populations. As part of a collaborative and compliance-focused team, you’ll contribute directly to the resolution of member and provider appeals while ensuring adherence to regulatory standards.
Position Overview
The Appeals Specialist I is responsible for investigating and resolving member and provider complaints, appeals, disputes, and grievances in compliance with state, federal, and internal regulations. This is a 100% remote position ideal for candidates with a background in managed care claims processing, Medicare/Medicaid policy, and strong communication skills.
Key Responsibilities
Conduct comprehensive research and resolution of appeals, grievances, disputes, and complaints from members, providers, or external agencies
Utilize internal systems to research claims and determine appropriate outcomes in accordance with regulatory requirements and timelines
Request and review medical records, clinical notes, and billing details as needed to support appeals processing
Apply benefits language and service coverage guidelines in evaluating each case
Draft appeal summaries, regulatory correspondence, and resolution letters accurately and concisely
Communicate decisions and case updates to members and providers via phone and written communication
Maintain production targets and accuracy standards set by the department
Identify trends and recurring issues; provide documentation upon request
Investigate root causes of payment errors by reviewing claims processing rules, fee schedules, and provider contracts
Respond to provider reconsideration requests and prepare written resolutions for claim adjustments
Required Qualifications
Education:
High School Diploma or GED required
Experience:
Minimum 2 years of operational experience in managed care (appeals, call center, or claims-related roles)
Knowledge of Medicaid and Medicare regulatory guidelines for denials and appeals
Experience with health claims processing including eligibility, subrogation, and coordination of benefits
Strong written and verbal communication skills, with attention to accuracy and detail