Appeals Specialist

We’re looking for a detail-oriented and motivated Appeals Specialist to join our team. In this role, you’ll review, research, and resolve healthcare claim appeals for accuracy and compliance with plan provisions, state and federal regulations, and internal procedures. 

• Review incoming appeals to determine appropriate handling and next steps.
• Analyze claim determinations, plan documents, and supporting documentation to ensure decisions are accurate and compliant.
• Draft professional, well-supported appeal determinations and correspondence.
• Collaborate with internal teams (claims, eligibility, customer service, and provider relations) to gather information and resolve cases.
• Track and document all appeal activity in internal systems with accuracy and clarity.
• Identify patterns or process issues contributing to appeal volume and communicate findings to leadership.
• Support continuous improvement by suggesting updates to policies, templates, or workflows.
• Maintain confidentiality and compliance with HIPAA and company policies.

• Strong attention to detail and organizational skills.
• 1–2 years of experience in a healthcare or insurance environment.
• 1-2 years of experience working with appeals.
• Strong ability to meet deadlines in a production environment.
• Excellent written and verbal communication skills.
• Ability to analyze data and documentation logically and objectively.
• Experience reviewing and interpreting plan documents.
• Comfortable managing multiple priorities in a fast-paced environment.
• Proficiency in Microsoft Office (especially Excel and Outlook).
• Eagerness to learn the healthcare and TPA industry from the ground up.

• Experience with medical, dental, or vision claim processing.
• Prior work at a TPA, health plan, or provider office.
• Familiarity with ERISA, state appeal timelines, or standard healthcare terminology (EOBs, CPT/ICD codes, etc.).
• Familiarity with the No Surprises Act.
• Exposure to claim systems or workflow platforms.