Appeals Specialist

This is a fully remote position, open to applicants in New York.

📋 Description

• Manage appeals from members and non-contracted providers for Healthfirst’s commercial, Medicaid, dual enrollment, Medicare, and complete care lines of business.

• Develop and address non-clinical cases, such as specific claim denials, member complaints, and appeals from both members and providers.

• Investigate issues while referencing internal health plan policies and procedures.

• Interpret regulations and make essential decisions regarding case resolution.

• Edit and finalize letters of resolution.

• Oversee caseloads and responsibilities within regulatory deadlines.

• Collaborate with colleagues to transfer or receive work tasks.

• Prepare and submit documented appeals in accordance with payer guidelines and timely filing requirements.

• Identify trends and patterns in denials and provide constructive feedback to leadership for process enhancement.

• Remain updated on payer policies, industry regulations, and coding changes.

• Undertake additional responsibilities as assigned.

⛳️ Requirements

• High School Diploma or GED from an accredited institution.

• At least two (2) years of professional experience in Managed Care Health Insurance Plans.

• Comprehensive experience handling appeals for Medicare, Medicaid, Dual enrollment, and commercial plans from start to finish.

• Preferred experience in claims processing with knowledge of coding criteria.

• Bachelor’s degree from an accredited institution or relevant work experience.

• Proven critical thinking and decision-making skills.

• Ability to maintain attention to detail, work under pressure, and manage tight deadlines.

• Availability to work Monday through Friday, from 8 am to 5 pm or 8:30 am to 5 pm EST.

• Must reside in an approved location; hiring range includes the Greater New York City Area (NY, NJ, CT residents) and other authorized locations.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Incentive and recognition programs.

• Life insurance coverage.

• 401k contributions.

• Competitive salary and benefits package.