Appeals Specialist

Job Title: Appeals Specialist

Job Overview:

The Appeals Specialist is responsible for managing and resolving appeals for out-of-network and in-network insurance claims, billing, or service-related issues. The Appeals Specialist is also responsible for handling arbitration disputes under the federal No Surprises Act and state surprise billing laws. This position requires a detail-oriented individual who can analyze complex cases, ensure compliance with industry regulations, and provide clear communication with clients, customers, or patients regarding the appeal process.

Key Responsibilities:

• Review and evaluate incoming appeal cases, including claims, billing issues, or service denials.
• Investigate the facts and circumstances surrounding each appeal, including reviewing relevant documentation, contracts, and communications.
• Process appeals in a timely manner, ensuring compliance with industry regulations and organizational policies.
• Collaborate with internal departments (such as claims, or billing teams) to gather necessary information and resolve appeals.
• Communicate directly with customers, clients, or patients, explaining the appeals process, decisions, and next steps.
• Maintain up-to-date records of all appeals, including documentation, decisions, and follow-up actions.
• Ensure that all decisions made are within company guidelines and legal requirements.

Skills and Qualifications:

• Bachelor’s degree in a relevant field (e.g., business, healthcare administration, or law) is preferred.
• Previous experience in out-of-network claims processing, legal, or related fields.
• Previous experience with No Surprises Act arbitration is preferred.
• Excellent communication skills, both written and verbal.
• Ability to analyze complex information and make informed decisions.
• Attention to detail and strong organizational skills.
• Proficiency in using computer systems and software (e.g., Microsoft Office, Practice Plus)
• Ability to manage multiple tasks and prioritize effectively.

IND2

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Application Question(s):

• what are your salary requirements?

Experience:

• Paralegal: 3 years (Required)

Work Location: In person