Health Plan Appeals Specialist

Martin's Point Health Care

. Process Medicare and US Family Health Plan member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals .

Posted 11/9/2026full-timePortland • Maine • United StatesMid-LevelSenior💰 $65,725 - $81,190 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing Medicare and TRICARE appeals processes, ensuring compliance with regulatory standards while maintaining high-quality communication and organizational skills. Proven ability to conduct complex investigations, manage multiple work queues, and implement process improvements effectively.

Highest-signal resume keywords

Medicare Advantage Appeals ProcessesTRICARE Appeals RegulationsClaims Review and Decision-MakingMicrosoft Office ProficiencyCustomer Service Excellence

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ReviewDecision-Making AuthorityCase ManagementRegulatory ComplianceProcess ImprovementData AnalysisAppeals OversightAudit PreparationProvider CredentialingAuthorization Processing

Soft Skills

Excellent Communication SkillsEffective Time ManagementStrong Interpersonal SkillsAttention to DetailSelf-Motivated

Tools & Technologies

Electronic Appeals Management SystemInternal Communication PlatformsMicrosoft WordMicrosoft ExcelMicrosoft PowerPoint

Industry Keywords

Managed CareMedicareTRICARECMS AuditsNCQA AuditsDHA AppealsOperational EfficienciesCase CommunicationsQuality ImprovementHealth Plan Regulations

About the role

Key responsibilities & impact

Process Medicare and US Family Health Plan member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals
Classify cases, including organization and coverage determinations for both lines of business
Review claims and exercise decision-making authority to reprocess claims in alignment with regulatory and internal policies
Conduct complex investigations involving claims review, provider credentialing, authorization processing, timeliness evaluations, and plan benefits design
Manage multiple work queues, including inbound mail, fax, voicemail, internal communication platforms, and the electronic Appeals management system
Communicate with external downstream entities, provider offices, customers, and internal business partners
Draft and issue regulatorily compliant case communications
Create, manage, and oversee case files and submissions to required review entities such as QIO and DHA
Monitor and track submitted cases through completion
Prepare files and participate in internal and external audits, including DHA, NCQA, and CMS audits
Prepare files for second-level appeals through DHA or ALJ
Support cross-departmental training, workflows, appeals trend reporting, and general appeals oversight
Conduct provider and beneficiary outreach to investigate and resolve appeals
Review and update policies, procedures, forms, workflows, and letter templates semi-annually
Evaluate and implement process improvements and operational efficiencies
Participate in system upgrade testing and support annual benefit development and regulatory changes related to appeals
Serve as a daily resource for staff and partner department questions and appeals-related escalations
Serve as subject matter expert for TRICARE and US Family Health Plan appeals manuals and CMS Part C and Part G guidance
Partner with Medical Directors and clinical support staff on appeals requiring clinical decision-making determinations
Maintain decision-making and communication timeframes after-hours and during holidays to meet regulatory and statutory requirements
Demonstrate the organization’s mission, vision, and core values

Requirements

What you’ll need

Bachelor’s Degree or equivalent experience and education
5+ years’ experience in managed care plan preferred
Knowledge of Medicare Advantage and/or TRICARE appeals processes and regulations strongly preferred
Excellent written and verbal communication skills
Effective time management and organization skills
Strong interpersonal skills and ability to collaborate with internal and external clients
Excellent customer service skills
Strong organizational skills and ability to meet deadlines, prioritize, and multitask
Understanding of and alignment with Martin's Point Values
Track record of producing high-quality, accurate work with attention to detail
Strong analytical, problem-solving, and mathematical skills
Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)
Self-driven and self-motivated, with ability to function independently and make sound decisions
Ability to take appropriate initiative while soliciting input/advice appropriately
Ability to handle confidential and sensitive information discreetly and professionally
Ability to handle high volume of work while maintaining accuracy and timeliness requirements
Not eligible for immigration sponsorship

Benefits

Comp & perks

Potential eligibility for additional compensation, such as incentive or commission-based programs, where applicable
Reasonable accommodations for applicants and employees with disabilities
Equal opportunity/affirmative action employer