Appeals Analyst

Job Title: Appeals Analyst

Location: Remote NC

Duration: 12 Months

We are seeking an experienced Appeals & Grievance Specialist to support the review investigation and resolution of healthcare-related appeals grievances claim disputes and coverage determinations. This role requires strong analytical communication and problem-solving skills along with experience in healthcare insurance operations and regulatory compliance.

The ideal candidate will be comfortable working in a fast-paced environment managing multiple cases conducting detailed research and ensuring accurate and timely case resolution.

• Investigate and resolve member and provider appeals grievances claim disputes and coverage determinations.
• Review claims benefit plans medical documentation and supporting records to determine appropriate outcomes.
• Interpret and explain healthcare benefits policies procedures and coverage information to members and providers.
• Prepare clear and professional written responses case summaries and supporting documentation.
• Maintain accurate and detailed records of investigations findings and actions within internal systems.
• Monitor case inventories and ensure timely completion of assigned work in accordance with established service standards.
• Collaborate with internal departments and clinical teams to support case resolution and decision-making.
• Ensure all work is completed in compliance with healthcare regulations company policies and quality standards.
• Handle confidential and sensitive information with professionalism and discretion.

• Bachelors degree or equivalent combination of education and related experience.
• 3 years of experience in healthcare insurance claims appeals & grievances or related healthcare operations.
• Experience with:
  • Medicare or managed care environments
  • Claims investigation or claims review
  • Appeals and grievance processes
  • Medical terminology and insurance benefits
• Strong written and verbal communication skills.
• Excellent organizational analytical and time management abilities.
• Ability to work independently and manage multiple priorities effectively.

• Experience handling coding disputes or claim denials.
• Knowledge of healthcare compliance and regulatory standards.
• CPC (Certified Professional Coder) certification or willingness to obtain certification.