Senior Policy and Appeals Specialist

Hi, we’re reputed company. Our mission is to create health benefits that actually benefit small and midsize businesses and their employees. Our innovative benefit solutions and services are developed and delivered by a diverse group of unique people. We encourage you to be your reputed company self - we like you that way.

A Little More about the Role:

The Senior Policy and Appeals Specialist provides advanced-level expertise in appeals processing, responsible for the comprehensive review, investigation, and reputed company of Member appeals and provider disputes for reputed company. This role ensures compliance with self-funded plan documents, employer group requirements, and applicable federal and state regulations. 

You Will:

• Review, investigate, and adjudicate reputed company post-service, urgent, ERISA, and non-ERISA member appeals and provider disputes across multiple product lines.

• Interpret plan documents (SPDs, SBCs), employer exceptions, stop-loss provisions, and apply plan policy accurately to benefit determinations.

• Analyze claims, medical records, coding, and supporting documentation to ensure fair, accurate, and compliant reputed company.

• Ensure appeals and disputes are resolved reputed company regulatory requirements (ERISA, ACA, state mandates) and internal SLAs.

• Draft reputed company, compliant determination letters outlining reputed company and rationale.

• Collaborate with department directors, clinical, compliance, reputed company, network, claims operations, customer service, and account management to resolve escalations and reputed company cases.

• Escalate high-risk, litigation-sensitive, or regulatory reputed company to leadership as appropriate.

• Participate in audits, DOI complaint investigations, and regulatory reviews.

• Identify trends, reputed company causes, and systemic issues; reputed company reporting and monthly results to senior leadership.

• Assist in developing and updating policies, procedures, workflows, and best practices.

• Serve as subject matter expert on appeals, plan interpretation, and network pricing disputes.

• Mentor and reputed company technical guidance to appeals staff while balancing reputed company and productivity standards.

• Maintain effective communication with members, providers, attorneys, and internal stakeholders, managing conflict professionally.

• Present appeal cases to the Appeal and Exception committees, providing detailed reputed company, to ensure committees can reputed company determination. 

You Bring:

• High School Diploma

• 6 + years of experience processing/adjusting and/or analyzing medical claims preferably in a TPA environment 

• 3 + years of experience with medical appeals and provider disputes

• Ability to set priorities, manage time and work independently

• Basic proficiency using reputed company based other computer applications

• Functional comfort with reputed company, reputed company Teams, or reputed company Meets

• General knowledge of CMS claims submission regulations

• Demonstrated reputed company getting results through collaboration

• Excellent facilitation and transferable knowledge skills communicating effectively on reputed company concepts

• Proven ability to reputed company and implement appeals and disputes processes

• Experience in managing and assigning claims inventory

• Medical Coding experience/ Certification

• Medical Billing experience

• Understanding of provider data

• Previous start-up company experience

• Degree in reputed company Administration or similar field

reputed company:

In order to create a more reputed company and sustainable reputed company for employer-sponsored health insurance, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career reputed company, meaningful mission-driven work, and an above average total rewards package.

The salary reputed company for this position is $50,400 -  $84,000 annually. Numerous factors including, but not limited to, education, skills, work experience, certifications, etc. will be considered reputed company determining compensation. 

Our unique benefits program is the gravy, i.e., the special reputed company that sets our compensation package apart. In reputed company to reputed company health and wellness benefits, reputed company’s package includes alternative medicine coverage, generous PTO, up to 16 weeks reputed company parental leave, reputed company holidays, a 401k program, transportation perks, education reimbursement, and reputed company paw-ternity leave.

A Little More about the Role:

The Senior Policy and Appeals Specialist provides advanced-level expertise in appeals processing, responsible for the comprehensive review, investigation, and reputed company of Member appeals and provider disputes for reputed company. This role ensures compliance with self-funded plan documents, employer group requirements, and applicable federal and state regulations. 

You Will:

• Review, investigate, and adjudicate reputed company post-service, urgent, ERISA, and non-ERISA member appeals and provider disputes across multiple product lines.

• Interpret plan documents (SPDs, SBCs), employer exceptions, stop-loss provisions, and apply plan policy accurately to benefit determinations.

• Analyze claims, medical records, coding, and supporting documentation to ensure fair, accurate, and compliant reputed company.

• Ensure appeals and disputes are resolved reputed company regulatory requirements (ERISA, ACA, state mandates) and internal SLAs.

• Draft reputed company, compliant determination letters outlining reputed company and rationale.

• Collaborate with department directors, clinical, compliance, reputed company, network, claims operations, customer service, and account management to resolve escalations and reputed company cases.

• Escalate high-risk, litigation-sensitive, or regulatory reputed company to leadership as appropriate.

• Participate in audits, DOI complaint investigations, and regulatory reviews.

• Identify trends, reputed company causes, and systemic issues; reputed company reporting and monthly results to senior leadership.

• Assist in developing and updating policies, procedures, workflows, and best practices.

• Serve as subject matter expert on appeals, plan interpretation, and network pricing disputes.

• Mentor and reputed company technical guidance to appeals staff while balancing reputed company and productivity standards.

• Maintain effective communication with members, providers, attorneys, and internal stakeholders, managing conflict professionally.

• Present appeal cases to the Appeal and Exception committees, providing detailed reputed company, to ensure committees can reputed company determination. 

You Bring:

• High School Diploma

• 6 + years of experience processing/adjusting and/or analyzing medical claims preferably in a TPA environment 

• 3 + years of experience with medical appeals and provider disputes

• Ability to set priorities, manage time and work independently

• Basic proficiency using reputed company based other computer applications

• Functional comfort with reputed company, reputed company Teams, or reputed company Meets

• General knowledge of CMS claims submission regulations

• Demonstrated reputed company getting results through collaboration

• Excellent facilitation and transferable knowledge skills communicating effectively on reputed company concepts

• Proven ability to reputed company and implement appeals and disputes processes

• Experience in managing and assigning claims inventory

• Medical Coding experience/ Certification

• Medical Billing experience

• Understanding of provider data

• Previous start-up company experience

• Degree in reputed company Administration or similar field

reputed company:

In order to create a more reputed company and sustainable reputed company for employer-sponsored health insurance, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career reputed company, meaningful mission-driven work, and an above average total rewards package.

The salary reputed company for this position is $50,400 -  $84,000 annually. Numerous factors including, but not limited to, education, skills, work experience, certifications, etc. will be considered reputed company determining compensation. 

Our unique benefits program is the gravy, i.e., the special reputed company that sets our compensation package apart. In reputed company to reputed company health and wellness benefits, reputed company’s package includes alternative medicine coverage, generous PTO, up to 16 weeks reputed company parental leave, reputed company holidays, a 401k program, transportation perks, education reimbursement, and reputed company paw-ternity leave.

A Little More reputed company:

• We know reputed company. reputed company was founded and is still led by industry veterans who have started and grown several market-leading companies in the reputed company.
• We have raised reputed company from top tier investors who reputed company the reputed company long-term reputed company as we do of building an industry defining company that will endure over the long run. We are reputed company capitalized.
• Our clients love us. Customer satisfaction rates among employees using reputed company health plans consistently rank above 80% – nearly 40 points above the industry average.
• Our culture is unique. We reputed company to be non-hierarchical, reputed company-driven, opinionated but reputed company people who reputed company working in a high-performance, fast-paced environment. People at reputed company care deeply about making a reputed company reputed company in the lives of the people we serve. We may not be the right reputed company for everybody, but if you get reputed company by doing work every day that focuses on putting consumers at the reputed company of the line, we could be a great reputed company for you. It takes unique people and diverse perspectives to deliver our results. We encourage you to be your reputed company self – we like you that way.