Appeals Specialist II (Healthcare)

TL;DR

Appeals Specialist II (Healthcare): Perform research, investigation, and analysis of appeals, grievances, and provider complaints with an accent on timely resolution, compliance with guidelines, and accurate case management. Focus on preparing customized responses, monitoring non-participating provider appeals, and collaborating with clinical staff and managers on complex cases.

Location: Remote (US-based with US-specific benefits like 401(k) and FSA)

Salary: $50,000–$55,000 annually

Company

Leading authority in payment integrity solutions including DRG Validation, Cost Outlier, and Readmission reviews for healthcare.

What you will do

• Prepare and disseminate case files for External Reviews and State Fair Hearings.
• Manage and monitor appeals from non-participating providers.
• Independently draft customized, well-written responses to provider inquiries and complaints.
• Conduct timely research, investigation, and resolution of appeals, grievances, and complaints in compliance with standards.
• Consult with managers, clinical supervisors, and experts to resolve complex cases.
• Log, track, and determine outcomes for appeals and grievances.

Requirements

• Associates Degree (or equivalent experience).
• 3+ years in healthcare industry, preferably with inpatient claims, DRG, and High-Cost Outlier experience.
• Experience in DRG Pricing using WebStrat.
• Knowledge of claim payment methodology.
• Strong MS Office skills, especially Excel; excellent analytical, problem-solving, and communication skills.
• Ability to manage priorities, meet deadlines, and handle stress in a complex environment.
• High-speed secured internet, dedicated workspace for HIPAA compliance.

Culture & Benefits

• Comprehensive medical, dental, vision coverage for employees and dependents.
• 401(k) with employer match.
• Generous PTO from day one, plus sick days and holidays.
• Wellness perks including commuter benefits and FSAs.
• Learning and development via on-the-job mentorship and LinkedIn Learning.