appeals specialist

Robert Half

<div>
 
 Appeals Specialist (Temporary Contract)
 
 
 
 Location:
 
 Remote
 
 
 
 Schedule:
 
 Full-Time | Monday&ndash;Friday | 8:00 AM &ndash; 4:30 PM
 
 
 
 Duration:
 
 Approximately 3 Months (through September 2026)
 
 
 
 Pay Rate:
 
 $21.50/hour
 
 
 Position Overview
 
 
 We are seeking detail-oriented and customer-focused Appeals Specialists to join a growing healthcare operations team. This fully remote opportunity is ideal for individuals with experience in healthcare administration, claims processing, customer service, or medical office support who enjoy research, problem-solving, and working in a fast-paced environment.
 
 
 In this role, you will support the review, intake, research, and processing of healthcare-related appeals and inquiries while ensuring accuracy, quality, and compliance with established guidelines. Successful candidates will possess strong organizational skills, the ability to manage multiple priorities, and a commitment to delivering high-quality work.
 
 
 Key Responsibilities
 
 <ul>
 <li>
 Review and research incoming correspondence, documentation, and requests to determine appropriate routing and handling
 </li>
 <li>
 Enter and maintain appeal cases and related information within internal systems
 </li>
 <li>
 Research and validate information using various databases, reference materials, and online resources
 </li>
 <li>
 Manage daily workload to meet established productivity, quality, and turnaround time expectations
 </li>
 <li>
 Accurately identify and triage expedited appeal requests
 </li>
 <li>
 Respond to internal inquiries via phone, email, and instant messaging as needed
 </li>
 <li>
 Process authorization-related requests and ensure appropriate documentation is obtained
 </li>
 <li>
 Assist with privacy-related activities and documentation requirements
 </li>
 <li>
 Support administrative functions including filing, scanning, printing, and document management
 </li>
 <li>
 Assist with scheduling activities and other operational support tasks as needed
 </li>
 <li>
 Collaborate with team members to achieve departmental goals and service standards
 </li>
 <li>
 Perform additional duties as assigned
 </li>
 </ul>
 
 
 
 
 Additional Information
 
 <ul>
 <li>
 Fully remote position
 </li>
 <li>
 Equipment provided
 </li>
 <li>
 Standard Monday&ndash;Friday schedule
 </li>
 <li>
 No overtime anticipated
 </li>
 <li>
 Opportunity to gain valuable experience within a large healthcare organization
 </li>
 <li>
 Collaborative and supportive team environment
 </li>
 </ul>
 
 If you enjoy research, problem-solving, and delivering high-quality work while supporting important healthcare operations, we encourage you to apply.
 
 
 
 Qualifications
 
 
 Required
 
 <ul>
 <li>
 High School Diploma or GED
 </li>
 <li>
 Minimum six months of experience in customer service, administrative support, healthcare operations, claims processing, or a related field
 </li>
 <li>
 Strong data entry and computer skills
 </li>
 <li>
 Experience working with multiple systems and databases simultaneously
 </li>
 <li>
 Ability to research information, analyze findings, and make appropriate decisions
 </li>
 <li>
 Excellent attention to detail and organizational skills
 </li>
 <li>
 Strong written and verbal communication abilities
 </li>
 <li>
 Ability to work independently in a remote environment
 </li>
 </ul>
 
 Preferred
 
 <ul>
 <li>
 Previous experience within the healthcare industry from either a payer or provider perspective
 </li>
 <li>
 Experience supporting appeals, claims, authorizations, benefits, or healthcare administration functions
 </li>
 <li>
 Familiarity with healthcare terminology and insurance processes
 </li>
 <li>
 Experience meeting productivity and quality performance metrics
 </li>
 </ul>
 
 Knowledge, Skills &amp; Abilities
 
 <ul>
 <li>
 Strong keyboarding and data entry accuracy
 </li>
 <li>
 Proficiency with Microsoft Office and Windows-based applications
 </li>
 <li>
 Ability to multitask and prioritize work effectively
 </li>
 <li>
 Strong problem-solving and critical thinking skills
 </li>
 <li>
 Ability to maintain confidentiality and handle sensitive information appropriately
 </li>
 <li>
 Excellent customer service and interpersonal communication skills
 </li>
 <li>
 Ability to adapt to changing priorities and business needs
 </li>
 <li>
 Strong commitment to quality, accuracy, and service excellence
 </li>
 </ul>
 
 
 
 
 TalentMatch
 
 &reg;
 
 
 
 
 Robert Half is the world&rsquo;s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.
 
 
 
 
 Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app and get 1-tap apply, notifications of AI-matched jobs, and much more.
 
 
 
 
 All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.
 
 
 
 
 &copy; 2025 Robert Half. An Equal Opportunity Employer. M/F/Disability/Veterans. By clicking &ldquo;Apply Now,&rdquo; you&rsquo;re agreeing to Robert Half&rsquo;s Terms of Use and Privacy Notice.
 
</div>

CW Appeals Specialist

MCS HEALTHCARE HOLDINGS, LLC

<div>Especialista Senior De Querellas Y Apelaciones 
Regular
Exempt 
GENERAL DESCRIPTION: 
Analyzes, investigates, resolves, and answers grievances received through the Center for Medicaid and Medicare Services (CMS) and Complaint Tracking Module (CTM), pre-service appeals, Office of Insurance Commissioner (OIC), and Administrative Organization Determinations (AOD). Ensure timely resolution of cases following contractual obligations and regulatory requirements applicable across all lines of business (LOB) in the company.
<div>ESSENTIAL FUNCTIONS: 
<ul><li>Records, manages, and resolves cases submitted through the CTM. Complies with verbal contact with the insured and/or authorized representative, or provider during the CTM case investigation process to document and categorize the issue presented, and review the documentation provided by operational areas to ensure proper resolution of cases.</li></ul></div><ul><li>Document in English the chronology of investigation and resolution on the CMS database, applying the contractual language of benefits and covered services according to the evidence of coverage, or others.</li><li>Evaluate in the investigation whether a root cause can be identified for the issue. If a root cause is determined, collaborate with the management of the affected operational areas to develop and implement corrective action plans aimed at minimizing the recurrence of CTMs or grievances.</li><li>Actively participate in the CTM workgroup, engaging with leaders from other Departments or Units to review RCA and coordinate on sustainable action plans to prevent future occurrences.</li><li>Complies with the validation and registration on electronic platforms, as applicable for the pre-service appeals processes, such as Clinical, USA, Dental, SSBCI, and Part B medication.</li><li>If a reconsideration or member request for a pre-service appeal is denied by the Classicare LOB, it is responsible for submitting the cases to the CMS contracted Independent Review Entities (IRE - Maximus). If the reconsideration or member request is denied by the MCS Life LOB, and the member requests a second-level appeal, it must follow the compliance guidelines of the OIC regulations and submit the cases to the Independent Review Organizations (IRO). Case files must be documented in English during the appeals process, considering the required records and timeliness.</li><li>Reviews and validates MCS Classicare members&rsquo; requests to determine eligibility for processing on the electronic platform, ensuring compliance with investigation protocols, evaluation standards, and timeliness requirements, following the company&rsquo;s Evidence of Coverage.</li><li>Document notes or chronology of CTM&rsquo;s, AOD&rsquo;s, and pre-service appeals investigations in the electronic platform to evidence proper management. This includes attachment of documentation related to the case and evidence of written notices to members or providers, based on the regulatory requirements.</li><li>Monitors CTM&rsquo;s and appeals processes to avoid impact on three (3) Stars metrics related to CTM, Appeals Timeliness, and Appeals Review (Upheld).</li><li>Supports in the unit rotation process by responding to inquiries related to pre-service appeals and AODs. Ensures appropriate referrals to other Departments for cases that do not qualify as appeals or AODs, assigns cases to relevant Specialists, and accurately updates internal logs and systems.</li><li>Responsible for overseeing the on-call program and monitoring processes related to the Unit. This includes supervision of corporate cell phone usage assigned to the Unit and ensuring timely access to staff by company personnel and regulatory agencies during and outside regular business hours, including evenings, weekends, and holidays. This is a regulated function that requires continuous availability and compliance with applicable regulatory requirements, to mitigate operational and compliance risks.</li><li>Complies with the delivery of data required by G&amp;A Analysts or immediate Supervisor to complete reports required by Regulatory Agencies, in the established timeframes and as requested (Example: CMS, ASES, OPP, OIC, other Departments, and/or MCS Units).</li><li>Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.</li><li>May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.</li></ul>
MINIMUM QUALIFICATIONS 
Education and Experience: Bachelor&rsquo;s Degree in Business Administration, Finance, Social Services, or Criminal Justice. At least four (4) years of experience in the areas of Research, Auditing, or Client/Provider Service, preferred in the Healthcare Insurance Industry.
&ldquo;Proven experience may be replaced by previously established requirements.&rdquo;
Certifications / Licenses: N/A Other: Knowledge of the following systems is preferred: HPMS, PMHS, Beacon Healthcare System, and TruCare.
Languages:
Spanish &ndash; Advanced (comprehensive, writing and verbal)
English &ndash; Advanced (comprehensive, writing and verbal) 
&ldquo;We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.&rdquo;</div>

Especialista Senior De Querellas Y Apelaciones

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.<div>
- Rework team hours of operation are Monday through Friday from 6:00 AM - 7:30 PM Central Standard Time (CST)
 
<ul><li>Schedule flexibility including nights, weekend, and holiday coverage.</li><li>This is a full time work from home position</li></ul></div>
Position Summary
Quality Specialist- Medicare D Quality role administers the quality management system to manage the review of clinical processes, documentation, and patient records. 
Interprets regulatory requirements from agencies and governing bodies to assist in the development of compliance policies and procedures. 
Additional Responsibilities to include but not limited to the following: 
<div> 
<ul><li>Learning the rework queues for each line of business</li><li>Working rework reports timely</li><li>Researching and troubleshooting failed claims</li><li>Adding and/or editing overrides in RxClaim</li><li>Logging audits and errors accurately and timely</li><li>Ability to identify trends and provide suggestions for process improvement</li><li>Researching and correcting any issues found in the overall process.</li><li>Raising issues to Coverage Determination Clinical Pharmacists and Management team as needed.</li><li>Reading, analyzing, and interpreting general business correspondence, technical procedures, and governmental regulations.</li><li>Solving practical problems and dealing with multiple concrete variables in standardized situations.</li><li>Performing basic mathematical calculations.</li><li>Ensuring all cases are properly closed.</li><li>Ability to interpret a variety of work instructions provided through multiple mediums.</li><li>Ability to anticipate needs and resolve issues with urgency and to meet quality and production standards.</li></ul> 

Required Qualifications</div><div><ul><li> 
2 years of Coverage Determination &amp; Appeals experience.</li><li>MHK, RxClaim, and People Safe proficient.</li><li>Meeting quality and productivity metrics in current role.</li></ul> 

Preferred Qualifications</div><ul><li>3 years of Coverage Determination &amp; Appeals experience.</li><li>1 year of Medicare PART B experience</li><li>MHK, RxClaim, and People Safe proficient.</li><li>Meeting quality and productivity metrics in current role.</li></ul> 
Education 
High School Diploma or equivalent GED
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$18.50 - $42.35
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 06/17/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Quality Specialist - Medicare D Quality

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CW Appeals Specialist

Especialista Senior De Querellas Y Apelaciones

Quality Specialist - Medicare D Quality

Quality Specialist - Medicare D Quality

Quality Specialist - Medicare D Quality

Quality Specialist - Medicare D Quality

Quality Specialist - Medicare D Quality