Appeals Specialist

Join Us in Shaping the Future of Health Care At MVP Health Care, we’re on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference—every interaction, every day. We’ve been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team. What’s in it for you Growth opportunities to uplevel your career A people‑centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team Competitive compensation and comprehensive benefits focused on well‑being An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace. About the Opportunity As an Appeals Specialist at MVP Health Care, you will play a crucial role in the nuanced landscape of healthcare, insurance or other related fields, focusing on reviewing and processing appeals related to service or coverage denials. The role demands a meticulous approach to understanding policies, regulations and specific circumstances surrounding each case. The Appeals Specialist ensures that every appeal is evaluated thoroughly and fairly, based on the merits of the case and applicable guidelines. Your efforts are instrumental in upholding the integrity of the decision‑making process, ensuring that each party’s rights are respected and the resolutions are reached in a timely manner. In this position, you contribute to the overall satisfaction and trust of the stakeholders involved, while also maintaining standards and reputation of MVP Health Care. Qualifications Bachelor’s degree in law, healthcare administration, business or related field required Associate’s Degree with minimum 5 years’ healthcare experience in lieu of Bachelor’s Degree Strong attention to detail and ability to manage multiple tasks simultaneously Excellent communication skills, both written and verbal Exceptional customer service skills and ability to handle difficult situations with empathy and professionalism Proficient in using computer systems and software, including Microsoft Office Suite Ability to work independently and as part of a team in a fast‑paced environment Strong organizational and time‑management skills What You’ll Do Review and analyze appeals requests ensuring that the cases are eligible for appeal Investigate and review routine and complex appeals Ensure compliance with State and Federal regulations, including accreditation requirements (e.g.: CMS, Medicaid, NCQA) Collaborate with internal and external stakeholders, as well as liaise with providers and enrollees as necessary to gather necessary documentation and information for appeals processing Maintain accurate and up‑to‑date records of appeals, including documentation of all communication in the department’s tracking system Monitor and track status of appeals, ensuring cases are processed within specified timeframes Prepare all appeals correspondence (acknowledgment, extension and resolution) Assist clients in understanding the appeals process and provide guidance on next steps Handle customer inquiries and resolve issues related to Medicare appeals in a professional and efficient manner Identify opportunities for process improvement and contribute to the development and implementation of best practices Stay updated on changes in regulations and guidelines to ensure compliance and provide accurate information to enrollees Analyze appeal outcomes to identify trends, patterns, issues with denials, recommending process improvement Location Hybrid Pay Range $51,395.00 - $68,354.75 Pay Transparency MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role. We do not request current or historical salary information from candidates. Inclusion Statement MVP's Inclusion Statement At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration. MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam‑era or special disabled Veteran or other legally protected classifications. Additional Information To support a safe, drug‑free workplace, pre‑employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at View email address on click.appcast.io. At MVP Health Care, we’re more than a health insurance company—we’re a mission‑driven organization committed to creating a healthier future for all. We believe in the power of innovation, collaboration, and continuous improvement to drive meaningful change. #J-18808-Ljbffr