Appeals Specialist

The Appeals Specialist is responsible for the timely, accurate, and compliant investigation and resolution of member and provider appeals and grievances. This role conducts comprehensive case research, evaluates applicable benefit plans, claims history, eligibility information, provider records, clinical or administrative documentation, and the circumstances surrounding an adverse determination. The Appeals Specialist prepares complete case files for clinical and/or administrative review, communicates case status and outcomes to internal and external stakeholders, and maintains clear documentation in designated systems. The position requires sound judgment, attention to detail, effective workload management, and consistent adherence to organizational policies, contractual requirements, and applicable regulatory standards and timeframes.

·       Conduct comprehensive research for assigned appeals and grievances, including review of enrollment and eligibility, provider participation status, benefit plan provisions, authorization records, claim history, clinical or administrative documentation, prior correspondence, and the circumstances surrounding the denial of services or rejection of claims.

·       Assess each submission to confirm that it meets applicable appeal or grievance criteria, identify the appropriate case type, category, subcategory, level of review, and root cause, and document the classification accurately in designated systems.

·       Validate case jurisdiction, timeliness, standing, authorization to represent, and required supporting documentation; identify missing or conflicting information and initiate appropriate outreach or escalation.

·       Apply relevant organizational policies, benefit language, contracts, regulatory requirements, and departmental procedures when researching and processing cases, escalating complex, urgent, or high-risk matters to the appropriate resource.

·       Prepare accurate, organized, and complete case files for clinical and/or administrative review, including a concise case summary, relevant evidence, prior determinations, correspondence, and any required review materials.

·       Communicate with members, authorized representatives, providers, vendors, and other stakeholders verbally and in writing in accordance with departmental standards and required timeframes.

·       Draft clear, professional, and accurate acknowledgment, information-request, status, and determination correspondence using approved templates and language, with appropriate review when required.

·       Document all case activity, research findings, decisions, communications, follow-up actions, and supporting rationale completely and accurately in the applicable systems.

·       Coordinate with internal departments and external resources, such as claims, customer service, utilization management, clinical reviewers, provider services, compliance, legal, and delegated vendors, to obtain information and support timely case resolution.

·       Maintain case records and supporting documents in accordance with departmental filing, naming, retention, privacy, and quality-assurance requirements.

·       Organize and submit case documentation for external or independent review in accordance with applicable regulatory, contractual, and departmental guidelines.

·       Manage an assigned caseload by prioritizing work according to due dates, case urgency, regulatory requirements, and departmental service-level expectations; monitor open tasks and complete follow-up activities promptly.

·       Meet established expectations for timeliness, accuracy, productivity, quality, and customer service, and promptly report barriers that may affect compliance or case completion.

·       Participate in training, calibration sessions, quality reviews, audits, and process-improvement activities; incorporate feedback and remain current on policy, system, product, and regulatory changes.

·       Protect confidential and sensitive information and follow all applicable privacy, security, and records-management requirements.

·       Perform other duties and support special projects as assigned.