Appeals Processor III

We are seeking a highly skilled Appeals Processor III (APP III) to join our dedicated team in a remote capacity. The Appeals Processor III (APP III) is responsible for reviewing, analyzing, and processing healthcare appeals related to Medicaid or Medicare coverage decisions. This role ensures all cases are handled in compliance with federal/state regulations, CMS guidelines, and contract requirements.

Requirements

• Associate’s Degree (Bachelor’s preferred)
• 2+ years in:
  • Healthcare appeals
  • Medical claims / utilization review
  • Insurance or Medicaid/Medicare processing
• Strong knowledge of:
  • CMS guidelines
  • Medicaid/Medicare (especially Part
    
    C)
  • Experience reviewing medical documentation (clinical roles may require RN)

Duties

• Review incoming appeals, medical records, and supporting documentation
• Analyze cases using state/federal regulations and CMS guidelines
• Determine if additional documentation is required and request it when needed
• Process appeals from start to finish, including final determinations

Decision Support & Documentation

• Prepare case summaries and ensure files are complete for review
• Draft or support writing determination/decision letters
• Ensure all documentation meets quality and compliance standards