CW Appeals Specialist

Description

We are looking for a detail-oriented Appeals Specialist to support a health insurance organization on a Contract basis. This role focuses on investigating complaints, grievances, and appeal-related concerns submitted by members, providers, legal representatives, and regulatory bodies while ensuring timely and accurate resolution. The position is fully remote, offering an opportunity to contribute in a fast-paced, high-volume environment where accuracy and clear communication are essential. Must be willing to work Pacific Time Zone hours.

Responsibilities:

• Investigate appeal cases, complaints, and grievance matters by gathering information from claims records, eligibility details, benefit plans, contracts, and prior case activity.

• Respond to concerns raised by members, providers, attorneys, and government agencies with clear, well-supported resolutions based on policy, contract terms, and applicable regulations.

• Maintain complete and accurate case documentation, ensuring all actions, findings, and outcomes are recorded properly for tracking and reporting purposes.

• Review system data and supporting files to identify inconsistencies, update records when corrections are needed, and help preserve data accuracy.

• Evaluate dispute issues within assigned authority levels and make determinations on contractual matters in accordance with established guidelines.

• Interpret member and provider contract language to assess appeal circumstances and apply benefit provisions appropriately to each case.

• Monitor recurring issue patterns, summarize findings, and communicate trends or potential defects to leadership for further review.

• Partner with customer service and internal support teams to address referred cases and resolve complex service concerns efficiently.

• Consistently meet productivity and quality expectations while managing a steady workload in a high-production environment.

Requirements

• Prior experience in health plan operations, ideally in appeals, grievances, claims, or complaint resolution.

• Hands-on experience using Facets is strongly preferred.

• Ability to work effectively in a high-volume setting while maintaining accuracy, organization, and timeliness.

• Working knowledge of health insurance benefits, claims administration, and contract interpretation.

• Strong written and verbal communication skills with the ability to correspond professionally with internal and external parties.

• Experience handling sensitive issues involving members, providers, legal entities, or regulatory agencies.

• Proficiency with databases, reporting tools, and case documentation practices.

• Ability to collaborate across teams and exercise sound judgment when resolving complex issues.

TalentMatch®

Robert Half is the world’s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.

Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app (https://www.roberthalf.com/us/en/mobile-app) and get 1-tap apply, notifications of AI-matched jobs, and much more.

All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.

© 2025 Robert Half. An Equal Opportunity Employer. M/F/Disability/Veterans. By clicking “Apply Now,” you’re agreeing to Robert Half’s Terms of Use (https://www.roberthalf.com/us/en/terms) and Privacy Notice (https://www.roberthalf.com/us/en/privacy) .