Appeals Specialist

TEKsystems • Happy Valley, OR

3d • $25 - $31 • Remote

About The Position

Handle the full lifecycle of member/provider appeals from intake and eligibility validation through analysis, decision-making, and closure. Review claims, medical/reimbursement policies, and contract terms to formulate appeal recommendations, and collaborate with coding specialists, nurses, and physician reviewers to reach timely decisions.

Requirements

• High school diploma/GED + 4 years' experience in customer service, claims, or clinical services (or equivalent combo of education/experience).
• Intermediate MS Office skills (Word, Excel, Outlook).
• Knowledge of medical terminology, anatomy, and coding (CPT, DX, HCPCs) preferred.
• Strong written/verbal communication, analytical, and multitasking skills.

Nice To Haves

• Coding certification a plus.

Responsibilities

• Validate appeal intake (timeliness, benefits, employer group, provider contracts) and document in system.
• Analyze claims, policies, and documentation to build appeal recommendations.
• Issue non-clinical determinations per department guidelines; coordinate clinical reviews as needed.
• Manage external review coordination, documentation, and communication with all parties.
• Track appeals and support reporting on trends, volume, and compliance.
• Serve as a courteous, professional point of contact for members/providers throughout the appeal process.

Benefits

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

What This Job Offers

• Career Level: Mid Level
• Education Level: High school or GED