Appeals Specialist

Healthfirst

. Process member and non-contracted provider appeals for Healthfirst’s commercial, Medicaid, dual enrollment, Medicare and complete care lines of business .

Posted 10/2/2026full-timeRemote • New York • United StatesJuniorMid-Level💰 $58,900 - $80,070 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in processing appeals for Medicare, Medicaid, and commercial plans, with a strong focus on critical thinking, decision-making, and adherence to regulatory timeframes. Proficient in managing caseloads, identifying denial patterns, and improving processes within the managed care health insurance sector.

Highest-signal resume keywords

Managed Care Health Insurance ExperienceAppeals Processing for Medicare and MedicaidClaims Processing ExperienceCritical Thinking and Decision-MakingDetail Oriented and Time Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Appeals ProcessingClaims ProcessingRegulatory InterpretationCase ResolutionCoding Criteria Knowledge

Soft Skills

Critical ThinkingDecision-MakingDetail OrientedAbility to Work Under PressureEffective Communication

Certifications & Qualifications

HS Diploma or GEDBachelor’s Degree (Preferred)

Industry Keywords

Health InsuranceMedicareMedicaidDual EnrollmentCommercial Plans

About the role

Key responsibilities & impact

Process member and non-contracted provider appeals for Healthfirst’s commercial, Medicaid, dual enrollment, Medicare and complete care lines of business
Develop and resolve non-clinical cases, including certain claim denials, member complaints, and member and provider appeals
Research issues and reference internal health plan policies and procedures
Interpret regulations and make critical case-resolution decisions
Edit and finalize resolution letters
Manage caseloads and duties within regulatory timeframes
Communicate with colleagues to hand off or pick up work
Prepare and submit documented appeals according to payer guidelines and timely filing limits
Identify denial patterns and trends and provide leadership feedback for process improvement
Stay current on payer policies, industry regulations and coding updates
Perform additional duties as assigned

Requirements

What you’ll need

HS Diploma or GED from an accredited institution
Minimum of two (2) years of work experience in Managed Care Health Insurance Plan
Experience with appeals for Medicare, Medicaid, Dual enrollment and commercial Plans end to end
Claims processing experience with coding criteria is preferred
Bachelor’s degree from an accredited institution or relevant work experience
Demonstrated critical thinking and decision-making competencies
Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes
Must work Monday through Friday, 8am–5pm or 8:30am–5pm EST
Residence in an approved location; hiring range distinguishes Greater New York City Area (NY, NJ, CT residents) and other approved locations

Benefits

Comp & perks

Medical, dental and vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Competitive compensation and benefits package