[Remote] Appeals Specialist
Note: The job is a remote job and is open to candidates in USA. Point C is a National third-party administrator (TPA) that delivers customized self-funded benefit programs. They are seeking a detail-oriented Appeals Specialist to review, research, and resolve healthcare claim appeals for accuracy and compliance with regulations and internal procedures.
Responsibilities
- Review incoming appeals to determine appropriate handling and next steps
- Analyze claim determinations, plan documents, and supporting documentation to ensure decisions are accurate and compliant
- Draft professional, well-supported appeal determinations and correspondence
- Collaborate with internal teams (claims, eligibility, customer service, and provider relations) to gather information and resolve cases
- Track and document all appeal activity in internal systems with accuracy and clarity
- Identify patterns or process issues contributing to appeal volume and communicate findings to leadership
- Support continuous improvement by suggesting updates to policies, templates, or workflows
- Maintain confidentiality and compliance with HIPAA and company policies
Skills
- Strong attention to detail and organizational skills
- 1–2 years of experience in a healthcare or insurance environment
- 1-2 years of experience working with appeals
- Excellent written and verbal communication skills
- Ability to analyze data and documentation logically and objectively
- Experience reviewing and interpreting plan documents
- Comfortable managing multiple priorities in a fast-paced environment
- Proficiency in Microsoft Office (especially Excel and Outlook)
- Eagerness to learn the healthcare and TPA industry from the ground up
- Experience with medical, dental, or vision claim processing
- Prior work at a TPA, health plan, or provider office
- Familiarity with ERISA, state appeal timelines, or standard healthcare terminology (EOBs, CPT/ICD codes, etc.)
- Familiarity with the No Surprises Act
- Familiarity with CMS terminology
- Exposure to claim systems or workflow platforms
Benefits
- Comprehensive medical, dental, vision, and life insurance coverage
- 401(k) retirement plan with employer match
- Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
- Paid time off (PTO) and disability leave
- Employee Assistance Program (EAP)
Company Overview