Healthcare Claims Appeals Specialist

Job Title: Healthcare Claims Appeals Specialist

Hours: Mon-Fri, 8 hours between 7am-530pm EST (40 hour/week)

Pay: $27-30/hr

Location: Remote (can sit in any state but must be able to work EST hours)

General Responsibilities
Independently administers and adjudicates healthcare payment disputes under the
Federal No Surprises Act Independent Dispute Resolution (IDR) process. Reviews and evaluates disputes between healthcare providers, facilities, and health plans to determine appropriate reimbursement amounts in accordance with applicable federal laws, regulations, guidance, and IDR requirements. Provides all parties with the opportunity to submit supporting documentation and evidence for consideration. Conducts impartial, evidence-based reviews and renders binding determinations based on the facts of the case, submitted materials, statutory and regulatory requirements, and established dispute resolution standards. Performs highly complex analytical and adjudicative work under general supervision, exercising substantial independent judgment, discretion, and decision-making authority.

Primary Duties
1. Adjudicate IDR Cases. Independently manage healthcare payment disputes arising under the No Surprises Act from case assignment through final determination using the CMS Federal IDR Portal and other designated systems.
2. Review Party Submissions and Evidence. Evaluate final payment offers, supporting documentation, and written arguments submitted by providers, facilities, and health plans. Ensure all submissions comply with applicable federal IDR requirements and procedural
standards.
3. Analyze Reimbursement Factors. Assess Qualifying Payment Amounts (QPA), provider training and experience, patient acuity, complexity of services, market share, prior contracted rates, and other permissible factors outlined in federal regulations.
4. Evaluate Clinical and Billing Documentation. Review medical records, itemized bills, clinical documentation, and related materials to determine the appropriateness of billed services and support evidence-based payment determinations.
5. Interpret Regulatory and Contractual Information. Research and analyze applicable federal statutes, regulations, guidance, payer information, fee schedules, and relevant contractual data to support dispute resolution decisions.
6. Issue Written Determinations. Prepare clear, objective, and well-supported written determinations that explain the rationale for payment selections and comply with
federal IDR requirements. Document status of dispute resolutions accurately.
7. Maintain Compliance and Neutrality. Ensure all dispute reviews and
determinations are conducted impartially and in accordance with No Surprises Act
regulations, CMS guidance, established procedures, and applicable timelines.
8. Communicate effectively with clients, providers, and internal departments to resolve issues.
9. Operate under general guidance; work assignments are varied and require interpretation and independent decisions on course of action.

Education
1. Bachelor's degree with 3 years' experience in medical billing, auditing or claims review, appeals or dispute resolution in healthcare or insurance industries, regulatory interpretation/application or related experience required; OR

2. Associates degree with 4 years' experience in medical billing, auditing or claims review, appeals or dispute resolution in healthcare or insurance industries, regulatory
interpretation/application, or related experience required.

Minimum Qualifications
1. Familiarity with healthcare claims and appeals processes.
2. Excellent interpersonal and communication (written and verbal) skills
3. Ability to successfully communicate and interact with healthcare providers and commercial payers or managed care organizations and internally with staff at all levels.
4. Ability to work independently, as well as in a team environment.
5. Exceptional organizational and time-management skills, attention to detail and ability to work at a fast pace.
6. Acute critical thinking and analytical skills.

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.