Appeals Specialist II

TEKsystems • Troy, NY

5d • $23 - $23 • Remote

About The Position

Supports the documentation and processing of appeals, disputes, and reconsiderations to ensure compliance with state and NCQA requirements. This role ensures timely review, accurate routing, and proper case resolution while maintaining strict adherence to company policies and standards.

Requirements

• High school diploma or GED required.
• 1–2 years of claim processing, prior authorizations, or utilization management experience.

Responsibilities

• Perform data entry to track, log, and process appeals, disputes, and reconsiderations in accordance with regulatory and accreditation guidelines.
• Prepare correspondence and maintain documentation files for appeals and disputes.
• Review and investigate appeals, disputes, and reconsideration requests to determine appropriate follow-up actions.
• Conduct research to evaluate and respond to appeals, ensuring timely decisions.
• Prepare case files with supporting documentation and determinations for review and reporting.
• Gather data to track and report on trends and outcomes, including outreach for status updates and determinations.
• Collaborate cross-functionally to ensure accuracy, efficiency, and compliance in case handling.
• Comply with all company policies, standards, and quality requirements.

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

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED