Appeals Specialist

The Appeals Specialist is a key member of the Appeals Operations and Provider Escalations & Educations teams, responsible for the timely processing and effective decision-making on appeals from plan providers, non-contracted providers, and members or their representatives. This role involves cross-functional collaboration with clinical, medical directors, utilization management, and claims teams to ensure appropriate appeal review decisions. The specialist manages the receipt, investigation, and resolution of appeals in a compliant and effective manner while maintaining current knowledge of company products and policies.