Appeals Specialist II

Health Care Service Corporation

. Process and adjudicate complex non-utilization management appeals according to applicable federal, state, and NCQA requirements and regulations.

Posted 11/6/2026full-timeRemote • United StatesMid-LevelSenior💰 $19 - $34 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in processing and adjudicating non-utilization management appeals while adhering to federal, state, and NCQA regulations. Strong communication skills are essential for responding to member inquiries and mentoring less experienced team members.

Highest-signal resume keywords

Non-Utilization Management Appeals ProcessingKnowledge Of Medical TerminologyFederal And State Guidelines ComplianceCustomer Service ExperienceVerbal And Written Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Appeals AdjudicationMedical Coding KnowledgeTask OrganizationDetail OrientationRegulatory Compliance Analysis

Soft Skills

MentoringCustomer AssistanceCommunication

Certifications & Qualifications

High School DegreeGED

Industry Keywords

Health InsuranceNCQA RequirementsCustomer Service RoleMedical Environment

About the role

Key responsibilities & impact

Process and adjudicate complex non-utilization management appeals according to applicable federal, state, and NCQA requirements and regulations.
Respond by phone, in person, or in writing to inquiries involving members’ requests for appeals.
May train and mentor less experienced Appeals Specialists.

Requirements

What you’ll need

High School Degree or GED.
3 years’ experience in a customer service role OR in a health insurance or medical environment.
Knowledge of medical terminology to include coding.
Experience and skills to analyze and assist customer based on knowledge of federal, state, and NCQA guidelines.
Experience and skills to organize tasks and accommodate large volume of reference materials.
Experience and skills to understand fine details of customer complaint issues.
Verbal and written communication skills.
This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii.

Benefits

Comp & perks

Curated development plans and professional development
Health and wellness benefits
401(k) savings plan
Pension plan
Paid time off
Paid parental leave
Disability insurance
Supplemental life insurance
Employee assistance program
Paid holidays
Tuition reimbursement
Other incentives
Annual incentive bonus plan, subject to plan terms and conditions