[Remote] Appeals Specialist

Note: The job is a remote job and is open to candidates in USA. Point C is a National third-party administrator (TPA) that delivers customized self-funded benefit programs. They are seeking a detail-oriented Appeals Specialist to review, research, and resolve healthcare claim appeals for accuracy and compliance with regulations and internal procedures.

Responsibilities

• Review incoming appeals to determine appropriate handling and next steps
• Analyze claim determinations, plan documents, and supporting documentation to ensure decisions are accurate and compliant
• Draft professional, well-supported appeal determinations and correspondence
• Collaborate with internal teams (claims, eligibility, customer service, and provider relations) to gather information and resolve cases
• Track and document all appeal activity in internal systems with accuracy and clarity
• Identify patterns or process issues contributing to appeal volume and communicate findings to leadership
• Support continuous improvement by suggesting updates to policies, templates, or workflows
• Maintain confidentiality and compliance with HIPAA and company policies

Skills

• Strong attention to detail and organizational skills
• 1–2 years of experience in a healthcare or insurance environment
• 1-2 years of experience working with appeals
• Excellent written and verbal communication skills
• Ability to analyze data and documentation logically and objectively
• Experience reviewing and interpreting plan documents
• Comfortable managing multiple priorities in a fast-paced environment
• Proficiency in Microsoft Office (especially Excel and Outlook)
• Eagerness to learn the healthcare and TPA industry from the ground up
• Experience with medical, dental, or vision claim processing
• Prior work at a TPA, health plan, or provider office
• Familiarity with ERISA, state appeal timelines, or standard healthcare terminology (EOBs, CPT/ICD codes, etc.)
• Familiarity with the No Surprises Act
• Familiarity with CMS terminology
• Exposure to claim systems or workflow platforms

Benefits

• Comprehensive medical, dental, vision, and life insurance coverage
• 401(k) retirement plan with employer match
• Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
• Paid time off (PTO) and disability leave
• Employee Assistance Program (EAP)

Company Overview