Appeals Specialist

Position Summary

The Appeals Specialist’s main function is to timely analyze, process and respond to Provider appeals related to payment denials of provider claim within the regulatory timelines set forth by the governing bodies and pursuant to contractual obligations.  The Appeals Specialist will also, conduct and record daily functions to ensure proper communication and documentation is made internally and externally.

Duties and Responsibilities

  • Research and review appeal submissions to determine if eligible for appeal based on defined criteria.
  • Research and prepare all qualifying appeals as assigned for Medicare, Medicaid, MMA, Commercial and Exchange lines of business. Classification for appeals may include the following: Payment disputes, filing limit disputes, denials for no authorization, benefit disputes, claim billing disputes, etc.
  • Review cases thoroughly to convey concise and accurate information for resolution based on, but not limited to, the following critical knowledge bases: general coding and billing policy, member eligibility, government and company compliance, provider contracts and terms, Network policies, correct coding including modifiers, CPT codes, place of service, authorizations, and referral requirements.
  • Consult with secondary reviewers such as Utilization Management and Claims Manager when needed.
  • Forward qualifying appeals for final review to Claims Manager and/or Medical Directors based on defined criteria.
  • Respond to any requests for additional information or consultation on appeals submitted to other departments and/or the Medical Directors.
  • Prepare notification and return documentation for incomplete or improperly submitted requests to the provider. Process non-appeals (i.e., refunds, adjustments, corrected claims, etc.) if necessary as defined by the submission type (i.e. First-time filing, submission of medical records, etc.)
  • Document, correspond and communicate with providers as needed and when required during appeal processing.
  • Properly document, track and process all appeals through the internal system.
  • Responsible for documenting and processing all Refund Requests made for overpayments made by the Network.
  • Ability to perform all other duties as assigned or requested.


  • Bachelor’s Degree or five years of equivalent experience in appeals processing in respective field.
  • Comprehensive knowledge of Appeals, Under and Over Payment, Claims Delegation and Contract Interpretation.
  • Knowledge in areas of appeal processing, including but not limited to Claims Processing, Coding and Billing, Medicare and governmental regulations.
  • Knowledge of HIPAA policies, Medical Terminology, ICD-10 and Procedural Knowledge is a required.

Skills & Abilities

  • Ability to write clearly and informatively. Edits work for spelling and grammar. Presents numerical data effectively and able to read and interpret written information.
  • Quality work is imperative for the department to run efficiently.
  • Exceptional interpersonal, verbal, and written communication skills.
  • Customer service-oriented attitude/behavior.
  • Ability to work with limited supervision and to make decisions based on established policies and procedures.
  • Problem analysis and problem resolution at both a strategic and functional level.
  • Ability to organize and manage multiple priorities.
  • Ability to interact effectively with all staff at all levels of management.
  • Ability to work under stress.

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear.  The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position.  Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting.  This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.  The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Performance Standards

Semi-annual performance appraisal.


This position requires about 10% travel.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

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