Review, investigate, and adjudicate complex member appeals and disputes.
Interpret SPDs/SBCs and apply plan policy to determinations.
Analyze claims, medical records, coding, and supporting docs for accurate decisions.
Ensure appeals comply with ERISA/ACA/state regs and internal SLAs.
Draft clear determination letters with decision rationale.
Collaborate with departments to resolve escalations and complex cases.

🎯 Requirements

High School Diploma
6+ years processing/adjusting/analyzing medical claims (TPA)
3+ years medical appeals and provider disputes
Ability to set priorities, manage time, and work independently
Knowledge of CMS claims submission regulations
Familiarity with Zoom, Microsoft Teams, or Google Meet

🎁 Benefits

Health and wellness benefits
Alternative medicine coverage
Generous PTO
Up to 16 weeks paid parental leave
Paid holidays
401k program

Apply on employer's website

This employer gathers applications via their own applicant tracking system.

You will be redirected to an external application form.

Share job

Meet JobCopilot: Your Personal AI Job Hunter

Automatically Apply to Healthcare Jobs. Just set your preferences and Job Copilot will do the rest — finding, filtering, and applying while you focus on what matters.

Activate JobCopilot