Job Description

Role Purpose

The Appeals Examiner plays a critical role within the team by managing and processing provider reconsiderations and  appeals with utmost accuracy and compliance.. The examiner collaborates with cross-functional teams to deliver timely resolutions and supports ongoing improvements in operational workflows.

This role requires dedication to upholding the integrity of benefit plan interpretation and commitment to high-quality case management. The Appeals Examiner will be integral in fostering positive relationships with providers and members by ensuring that each appeal is handled with attention to detail and professionalism.

As a part, you will contribute to a dynamic team environment focused on delivering excellence in healthcare service operations while developing your expertise in benefit administration and regulatory compliance.

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Essential Job Functions and Duties

• Coordinate comprehensive review and resolution of member appeals and provider disputes, ensuring compliance with Department of Labor regulations and client-specific service level agreements (SLAs).
• Meticulously document all case actions and outcomes to maintain accurate records for auditing and quality assurance purposes.
• Collaborate closely with internal teams, including medical review and adjustment departments, to facilitate escalations and timely resolution of complex cases.
• Utilize problem-solving skills to interpret Summary Plan Documents, enabling accurate determination of appeal validity and appropriate responses.
• Ensure strict adherence to HIPAA and privacy guidelines with regard to the confidential handling and release of member and provider information.
• Engage in ongoing communication with providers, members, and stakeholders to clearly convey appeal decisions and next steps.
• Assist in research and response to member complaints, working alongside both internal departments and external contacts as necessary.
• Support continuous improvement by recommending process enhancements and sharing insights during team meetings and training sessions.
• Perform additional duties as assigned to contribute to the overall success of the appeals and grievance department.

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Qualification Requirements

• High School diploma or GED equivalent required; additional education or certifications related to healthcare administration or insurance processes are a plus.
• Proven problem-solving abilities with a focus on interpreting benefit plans and related documentation accurately.
• Working knowledge or familiarity with healthcare coding systems such as CPT and ICD-9/ICD-10, as well as medical terminology, strongly preferred but not mandatory.
• Ability to work effectively with minimal supervision while managing multiple priorities in a fast-paced environment.
• Proficiency in standard computer applications (Microsoft Office Suite) and experience with specialized claims or case management software is advantageous.
• Demonstrated average to above-average typing skills to ensure efficient data entry and documentation.
• Excellent interpersonal and communication skills, enabling professional interaction with members, providers, and team members.
• A strong commitment to confidentiality, accuracy, and compliance with regulatory standards.