Appeals Specialist

Description Responsible for all activities associated with appeal analysis, decision-making and closure as described below: Appeal Intake Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal. Document information in appropriate system. Appeal Analysis Review claim coding and claim processing history, medical policy and reimbursement policies, regulatory and legal requirements, benefit contracts, and/or provider contracts. Collect and catalogue supporting documentation and formulate an appeal recommendation. Document information in appropriate system. Apply knowledge and experience to answer a variety of increasingly complex inquiries from members, providers, and provider representatives. Collaborate effectively with coding specialists, appeal nurses, physician reviewers, and others as necessary to reach timely decisions on appeals. Decision & Closure Make non-clinical appeal determinations as permitted by department business processes and guidelines. Follow departments processes to receive a clinical review and decision from licensed health professionals. Present complex cases to appeal panels, document decisions, communicate determinations to members, providers or their representatives. Document information in appropriate system(s). External review process Oversee set-up of appeals for external review organizations, including document collection and coordination, communication with all parties, and other responsibilities as an intermediary between the provider and the external review organization. Ensure external review information is documented in appropriate system. Prepares letters and cases for external review as needed. Implement external review decisions. Interpersonal and Communication Provide information, education and assistance to members, providers, and their representatives. Facilitate the members or providers understanding of the appeal process and of the information necessary to effectively process an appeal. Be a courteous advocate to the member or provider when requesting supporting information. Work cooperatively and effectively across all business areas to resolve. Systems and data Track appeals in appropriate systems and assist in the maintenance of files. Assist with compilation of reports on appeals, including trends, number of cases, decisions, suggestions for process improvement, types of appeals, and compliance with timelines. Support, apply and promote Provider or Member Appeal Policies & Procedures. Adhere to dependability, customer focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all work. Manage a defined caseload within department productivity and quality expectations and provide back up for other appeals staff. May perform as expert witness during any level of appeal, regarding policies, procedures and member or provider appeal rights. Meet timeliness standards as set forth through department policies and procedures, subscriber summary plan descriptions, performance guarantees, and regulations. Skills Customer service, Administration Top Skills Details Customer service,Administration Competencies And Knowledge Excellent verbal and written communication skills. Intermediate computer skills (e.g. Microsoft Word, Excel, Outlook) and experience with Regence systems. Knowledge of medical terminology, anatomy and coding (CPT, DX, HCPCs). Knowledge of Regence claims processing and clinical services operations. Demonstrated initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing a course of action. Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all aspects of internal and external contacts. Ability to present complex medical and reimbursement information to others and to be diplomatic and persuasive regarding health plan benefits, claims and eligibility. Ability to switch from one task or type of work to another as the business needs require. Ability to effectively prioritize work to meet strict timelines while maintaining quality and consumer centric focus. Normally To Be Proficient In The Competencies Listed Above Appeals Specialist I would have a high school diploma or GED and a minimum 4 years experience in Regence Customer Service, Claims, or Clinical Services or equivalent combination of education and work experience. Required Licenses, Certifications, Registration, Etc. Coding Certification preferred for Specialist I. Job Type & Location This is a Contract to Hire position based out of Portland, OR. Pay And Benefits The pay range for this position is $25.00 - $31.00/hr. Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type This is a fully remote position. Application Deadline This position is anticipated to close on Oct 9, 2026. About TEKsystems We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company. The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. About TEKsystems And TEKsystems Global Services We're a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We're a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. We're strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. We're building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records. Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools. #J-18808-Ljbffr TEKsystems