Medical Appeals Representative 5276

Make a Difference in Healthcare by Supporting Fair and Timely Appeals Decisions

Are you experienced in healthcare claims, insurance operations, or appeals processing? Do you enjoy solving problems, working with complex information, and helping ensure members receive accurate and timely decisions regarding their healthcare benefits?

We're seeking a Medical Appeals Representative to join our healthcare operations team. In this role, you'll play a critical part in the medical appeals process by reviewing, prioritizing, coordinating, and tracking appeals to ensure they are handled accurately, efficiently, and in compliance with regulatory requirements.

This is an excellent opportunity for healthcare and insurance professionals who thrive in a fast-paced environment and enjoy working with claims, benefits, compliance, and cross-functional teams.

What You'll Do

As a Medical Appeals Representative, you'll serve as the operational backbone of the appeals process, helping ensure cases move efficiently from intake through resolution.

Key Responsibilities

• Review incoming medical appeals received through mail, fax, and electronic channels.
• Determine whether appeals qualify for expedited or standard review based on established guidelines and regulatory requirements.
• Create, document, and maintain appeal cases within internal systems.
• Prioritize and route appeals to the appropriate clinical reviewers and business partners.
• Track appeal activity to ensure cases are processed within required turnaround times.
• Research claims, benefits, and supporting documentation to facilitate accurate appeal reviews.
• Assist with appeal case preparation, workflow coordination, and documentation management.
• Maintain accurate records to support compliance, audit readiness, and reporting requirements.
• Collaborate with internal teams to resolve issues and ensure timely case completion.
• Identify opportunities to improve workflows and enhance operational efficiency.
• Ensure compliance with HIPAA, accreditation standards, and applicable federal and state regulations.

Required Experience

• Minimum of three (3) years of experience within healthcare insurance, benefits administration, claims research, or healthcare operations.
• At least two (2) years of experience supporting claims processing, customer service, appeals, or related healthcare functions.
• Experience interpreting health plan benefits and researching claim-related issues.

Preferred Experience

• Medical appeals, grievances, or utilization management experience.
• Healthcare payer or managed care experience.
• Experience with Medicare, Medicaid, or commercial health plans.
• Familiarity with healthcare regulatory and accreditation requirements.
• Experience working with healthcare claims and appeals systems.

Knowledge & Skills

• Strong understanding of health insurance benefits and claims processing.
• Familiarity with CPT, ICD-10, and HCPCS coding systems.
• Excellent analytical, organizational, and problem-solving skills.
• Ability to prioritize multiple deadlines in a fast-paced environment.
• Strong written and verbal communication skills.
• High attention to detail and commitment to accuracy.
• Ability to work independently while collaborating effectively with cross-functional teams.

Preferred Systems Experience

Experience with one or more of the following:

• EPIC
• Facets
• ESI
• Provider Portals
• Common Query
• Adobe Standard
• Microsoft Office Suite (Word, Excel, Outlook)

Why Join Us?

This role offers the opportunity to make a meaningful impact on healthcare outcomes by helping ensure appeals are handled fairly, accurately, and within regulatory timelines. You'll work alongside experienced clinical and operational professionals in a collaborative environment where your expertise and attention to detail directly contribute to member satisfaction and organizational success.

If you're passionate about healthcare operations, enjoy investigating complex issues, and want to be part of a team that helps improve the member experience, we'd love to hear from you.