Appeals Specialist II

Computer and Data Entry Skills: Ability to navigate multiple systems simultaneously, manage high-volume workloads, and demonstrate strong typing and computer skills. The ideal candidate has experience with claims processing, prior authorizations, or utilization management, along with strong analytical skills, attention to detail, and the ability to work efficiently across multiple systems.

Appeals Specialist II

Contract Type / Duration: 6-month contract; potential to extend or convert
Target Start Date: November 30, 2026
Location: Remote candidates must be located in an EST or CST time zone
Work Hours: Monday Friday, 40 hours per week. No weekends or overtime.
Post-Training Schedule: Candidates may select from three available shifts beginning at 8:00 AM, 8:30 AM, or 9:00 AM EST.
Pay Rate: $23.00/hour

Position Overview

We are seeking an Appeals Specialist II to support the review, investigation, documentation, and processing of claims reconsiderations, appeals, and disputes. This role serves as an initial decision-making point, reviewing approximately 50 cases per day to determine the appropriate next steps and route cases for resolution.

The ideal candidate has experience with claims processing, prior authorizations, or utilization management, along with strong analytical skills, attention to detail, and the ability to work efficiently across multiple systems.

Top Required Skills (Ranked)

1. Claims Resolution and Reconsiderations: Experience reviewing claims disputes, reconsiderations, and authorization-related issues.

2. Prior Authorizations / Utilization Management: Understanding of authorization requirements, authorization records, and medical necessity documentation.

3. Computer and Data Entry Skills: Ability to navigate multiple systems simultaneously, manage high-volume workloads, and demonstrate strong typing and computer skills.

Key Responsibilities

• Review and investigate approximately 50 assigned claim reconsideration cases daily.

• Determine whether prior authorization was required for services rendered.

• Verify that authorizations are on file and accurately reflect dates of service, units, procedure codes, and providers.

• Review supporting documentation for medical necessity, service-specific requirements, and other relevant circumstances.

• Identify missing medical records or documentation needed for case review.

• Determine the appropriate next steps and route cases to the correct department for resolution.

• Prepare case documentation and provide clear instructions to claims and authorization teams.

• Track case statuses, outcomes, and required follow-up.

• Maintain accurate records and meet established productivity and quality standards.

Performance Expectations

• Complete approximately 50 cases per day after training and ramp-up.

• Maintain a quality audit score of at least 95%.

• Demonstrate accuracy with minimal to no identified errors.

• Remain productive throughout the full work shift and communicate effectively with team members.

Preferred Skills / Nice to Have

• TruCare experience.

• Experience with claims reconsiderations, disputes, or appeals.

• Familiarity with prior authorization and utilization management workflows.

• Experience working in multiple healthcare systems simultaneously.

Education Requirements

• High school diploma or GED required.

• 1 2 years of related experience required, preferably in claims processing, prior authorizations, or utilization management.

Certifications

• No certifications required.