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Claims Appeals Specialist - Healthcare (Remote)

Long Beach, CA

Job Title: Specialist for Claims Appeals Resolution

Salary: $65,000-$90,000 + Medical Benefits offered

Typical Schedule/Shift: Monday - Friday, 7:30 AM - 4 PM or 8 AM - 4:30 PM


Join our team as an Appeals Resolution Specialist where you will be instrumental in reviewing and addressing member and provider concerns. Your role involves ensuring that resolutions align with the standards and requirements mandated by the Centers for Medicare and Medicaid Services (CMS). With a minimum of 2 years of experience working directly with claims adjudication, you will bring valuable expertise to our organization, ensuring compliance and maintaining exceptional service standards.

Primary Responsibilities:

Resolution Management: Review and resolve member and provider concerns in accordance with CMS standards and requirements.

Effective Communication: Clearly communicate resolutions to members, providers, or their authorized representatives, ensuring comprehension and satisfaction.

Documentation: Maintain meticulous records of all complaints and their resolutions for tracking and auditing purposes.

Regulatory Compliance: Stay updated on the latest CMS guidelines and regulations pertaining to complaint resolution and ensure adherence.

Quality Assurance: Engage in quality assurance initiatives to improve the efficiency and accuracy of the resolution process.

Process Enhancement: Identify areas for process improvement and contribute to refining the overall effectiveness of the appeals process.


Experience: A minimum of 2 years of experience in complaint resolution or appeals within the healthcare industry, with a strong background in claims adjudication.

Regulatory Familiarity: Understanding of CMS standards and requirements related to complaint resolution.

Communication Skills: Excellent verbal and written communication abilities to effectively convey resolutions to various stakeholders.

Attention to Detail: Exceptional attention to detail to uphold accurate records and ensure regulatory compliance.

Problem-Solving Skills: Strong problem-solving abilities to address complaints efficiently and effectively.

Adaptability: Flexibility to adapt to evolving guidelines and procedures.

Team Collaboration: Ability to work collaboratively as part of a team to achieve shared objectives.

Work Arrangement:

This position operates on a typical Monday to Friday schedule, with shifts available from 7:30 AM to 4 PM or 8 AM to 4:30 PM. This is a contract-to-permanent opportunity that is full-remote.

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