Appeals Coordinator


Durham, North Carolina

a month ago

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Appeals Coordinator
Durham, North Carolina

a month ago

Job Description

Job Title: Appeals Coordinator
Duration: 6 months
Training Hours: 8am- 5pm EST.
Location: Remote, must be located in any one of the following states (Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.)

This role is supporting an increase in Behavioral Health claims on the Members side of the business, and will be the first point of contact for all appeals not just Behavioral Health.  This team on average reviews all claims and determines that roughly 40% are valid to move forward and 60% are invalid or need additional information. 
Experience in claims and a Healthcare background are highly preferred.
Candidates must be proficient in working on a PC, in MS Office (mostly Outlook, Teams, and Word).
Candidates must be able to work remotely and manage their desk as needed.

Job Description:
  • Performs initial research and documentation of all incoming appeals and, grievances. Demonstrates the ability to research benefits, Plan policies, provider contracts, and determine the appropriate time frames applicable to an incoming request
  • Determines the validity of all incoming appeals and makes critical decisions to keep and work as a valid appeal or send letter back to requestor indicating the appeal is non-valid and provide rationale for the non-valid decision. Provide member education regarding appropriate submission of inquiries.
  • Provides mandated written responses to appellants of receipt of appeal, need for additional information and may provide interim responses giving notice of an extension of the appeals process to unforeseen delays, (i.e.) Acknowledgement letters and 3rd party authorizations forms, Appointment Of Represenative and Waiver Of Liability forms.
  • Researches all department requests, set up, and assign cases, as well as maintain files within the unit
  • Identifies all misrouted inquiries and handles accordingly
  • Provides direct feedback to Appeals Department management for identified problems
  • Identifies additional tasks and works independently to ensure all up front functions run smoothly, which may include scanning and imaging as required, answer member/provider questions via incoming telephone calls in a professional quality driven manner
  • Analyzes and coordinates all aspects of the appeals process to ensure compliance with our medical necessity criteria, Corporate Medical Policy, contract provisions, NC DOI, legislative and NCQA requirements
  • Sorts, and distributes all incoming request via direct mail, right fax and Macess in a timely efficient manner throughout the day to ensure regulatory filing requirements are met 
  • Date stamp and initial all incoming correspondence via direct mail

Hiring Requirements

• High school diploma or GED

• 0-2 years of experience in related field.


About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at:
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at if you require reasonable accommodation. 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $22.71/hr.

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