Accountabilities:

Manage the receipt, investigation, review, and resolution of appeals submitted by health plan members, contracted and non-contracted providers, and authorized representatives.
Ensure all appeals are processed accurately, efficiently, and within established timelines and applicable regulatory requirements.
Conduct detailed case investigations, gathering relevant information and documentation to support appropriate and well-informed appeal decisions.
Coordinate with internal departments, including Clinical, Medical Directors, Utilization Management (UM), and Claims teams, to obtain necessary information and ensure comprehensive case reviews.
Collaborate with managers, external vendors, and other stakeholders throughout the investigation and resolution process, including preparing cases for internal or external review when required.
Communicate with members, healthcare providers, and their representatives through written correspondence and telephone calls, providing clear explanations and appropriate updates.
Maintain accurate records of all communications, investigations, decisions, and case outcomes in accordance with internal procedures and documentation standards.
Develop and maintain a thorough understanding of healthcare products, policies, procedures, and appeal guidelines to provide accurate and consistent information to internal and external stakeholders.
Complete required data entry and documentation across multiple systems, ensuring accuracy and completeness of information, including all applicable Centers for Medicare & Medicaid Services (CMS) reporting requirements.
Identify and address discrepancies or missing information to maintain data integrity and support compliant appeals operations.
Contribute to the effectiveness of the Appeals Operations and Provider Escalations teams through strong collaboration, problem-solving, and continuous process improvement.

Requirements

Bachelor's degree in Healthcare, Conflict Resolution, or a related field, or equivalent relevant professional experience.
Strong computer skills, with the ability to navigate multiple systems, manage electronic records, and perform accurate data entry.
Excellent analytical and investigative abilities, with the capacity to evaluate complex information, identify discrepancies, and support sound decision-making.
Exceptional attention to detail, particularly when handling sensitive information, maintaining case documentation, and ensuring data integrity.
Excellent written and verbal communication skills, with the ability to explain policies, procedures, and appeal decisions clearly and professionally.
Strong interpersonal and customer service skills, with the ability to communicate effectively and empathetically with members, providers, and internal stakeholders.
Demonstrated problem-solving and conflict-resolution abilities, particularly when managing complex or sensitive appeal situations.
Strong organizational and time management skills, with the ability to manage multiple cases, prioritize competing deadlines, and meet established service requirements.
Ability to work collaboratively with cross-functional teams, including clinical professionals, medical directors, claims specialists, and external partners.
High level of professionalism, accountability, and discretion when handling confidential healthcare and member information.
Working knowledge of healthcare insurance products, policies, procedures, and claims processes is highly desirable.
Previous experience in healthcare appeals, insurance operations, provider relations, or case investigation is an advantage.
Ability to adapt to changing priorities while maintaining accuracy, compliance, and high-quality service.

Benefits

Competitive hourly compensation: $23–$30 per hour, depending on qualifications, relevant experience, education, specialized skills, and work location.
Employer-sponsored healthcare coverage, including medical, dental, and vision insurance, with low or no employee premiums.
Generous paid time off.
Monthly mobile phone or internet stipend of $100.

How Jobgether works

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

Why Apply Through Jobgether?

Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.

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