Medical / Healthcare - CW Medical Appeals Representative

Medical Appeals Representative

Provides operational support for the intake, prioritization, and coordination of medical appeals to ensure timely and compliant processing. This role performs initial review of incoming appeals, differentiates between expedited and standard requests, and facilitates accurate routing to appropriate clinical staff. The position requires strong attention to detail, independent work capability, and adherence to HIPAA, regulatory, and accreditation standards.

Ensures the timely and accurate processing of all medical appeals by performing intake review, prioritization, and case coordination activities. Supports departmental workflow by organizing, distributing, and tracking appeals while ensuring compliance with PPACA, Department of Insurance (DOI), and URAC guidelines.

Reviews incoming appeal requests (mail, fax, electronic) to determine eligibility and classification. Differentiates between expedited and standard appeals to ensure compliance with regulatory timeframes. Establishes and maintains appeal cases within designated systems (e.g., EPIC). Prioritizes, organizes, distributes, and tracks appeals to appropriate clinical staff. Coordinates workflow to ensure timely processing and adherence to service level expectations. Performs research and prepares documentation to support appeal processing. Assists Medical Appeals Specialists during periods of high volume or absence, including case setup, routing, and processing. Maintains accurate records and documentation in compliance with data retention and audit requirements. Ensures adherence to HIPAA, accreditation standards, and all applicable federal and state regulations. Collaborates with internal departments to support resolution and ensure compliance. Identifies process improvement opportunities and communicates recommendations to leadership. Performs additional duties as assigned within the scope of the role.

Nature and Scope: Individual contributor role with no direct reports. Reports to: Supervisor, Medical Appeals. Operates in a high-volume, deadline-driven environment requiring independent work and prioritization.

Key Internal/External Contacts: Appeals and Grievances, Member Services and Customer Service, Provider Services and Network Administration, Medical Management, Legal, Marketing and Accounts Payable.

Minimum Qualifications: Education: High School Diploma or equivalent required. Work Experience: 3 years of insurance experience, including benefits and claims research (required); 2 years of experience in customer service and/or claims processing (required). Experience may run concurrently. Experience with Facets application (preferred).

Knowledge, Skills, and Abilities: Knowledge of health insurance benefits and claims processing procedures. Ability to interpret benefit plans across multiple lines of business. Familiarity with CPT, ICD-10, and HCPCS coding systems. Understanding of accreditation standards, regulatory requirements, and internal systems. Strong organizational, prioritization, and time management skills. High attention to detail and accuracy. Ability to work independently in a fast-paced and changing environment. Strong written and verbal communication skills. Proficiency in Microsoft Office applications (Word, Excel).

Preferred Technical Knowledge: EPIC, Facets, Client Provider Portal, Common Query, Adobe.

Standard Work Environment: Primarily onsite at corporate office. Standard office environment with minimal physical demands. May require independent work with limited supervision. Flexibility required to support team coverage and workload demands.

Licenses and Certifications: None required.

EEO: "Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans."