Appeals Associate - Fully Remote

We are seeking an Appeals Associate with at least 3 years of experience in healthcare appeals, coding disputes, and grievance resolution. The ideal candidate will have a Certified Professional Coder (CPC) certification and expertise in health plan benefits, regulatory guidelines, and accreditation compliance.

Responsibilities of the Appeals Associate:

• Analyze, research, and resolve confidential/sensitive appeals, coding disputes, and grievances from members, providers, and regulatory agencies.
• Interpret and explain health plan benefits, policies, procedures, and medical terminology to stakeholders.
• Prepare files and develop position statements for external reviews by independent organizations.
• Provide comprehensive appeal and dispute responses that comply with state and federal regulatory guidelines.
• Gather clinical information using corporate medical policies, partnering with Medical Directors for appeal and grievance resolutions.
• Monitor daily reports to ensure service timeliness and compliance with NCQA, CMS, ERISA, and NCDOI accreditation standards.
• Maintain accurate documentation of investigations and findings in relevant systems.

Qualifications of the Appeals Associate:

• Bachelor’s degree or higher (or 5 years of relevant experience in lieu of a degree).
• Certified Professional Coder (CPC) required.
• Strong ability to exercise independent judgment, ensuring compliance with healthcare policies.
• Experience with external review organizations, benefit panels, and medical consultants.
• Knowledge of accreditation standards, and state/federal healthcare regulations.

Compensation of the Appeals Associate:

• Salary: $25–$28/hr, based on experience.
• Schedule: Monday–Friday, Remote.
• Benefits: Medical, Dental, Vision, 401k, and sick leave as required by law.

Application Details:

Applications for this position will be accepted for at least 30 days from the posting date.

Keywords:

Appeals associate, medical appeals, CPC, coding disputes, grievance resolution, health insurance, regulatory compliance, NCQA, CMS, ERISA, remote

#LI-KI1 #LI-REMOTE