Appeals Analyst

About the role

As an Appeals Analyst, you’ll review provider appeals by applying established procedures, service level agreements, plan documents, and network contract requirements to ensure accurate and timely claim determinations. You’ll calculate and negotiate settlement offers, prepare agreement documentation, issue denial determinations when appropriate, and coordinate approvals that exceed delegated authority while maintaining compliance with ERISA and applicable federal and state regulations. You’ll also maintain detailed records of appeal activity and outcomes, ensure claims are priced according to finalized terms, communicate statuses and resolutions with clients and providers, and utilize Zendesk, internal claims systems, Microsoft Outlook, and Microsoft Teams to support efficient case management and workflow.

Location: Fully remote, US‑based; equipment provided; need a quiet workspace, reliable internet, adherence to security protocols (VPN, secure passwords, approved devices/software), and HIPAA compliance.

Responsibilities

• Review appeals received from providers while adhering to established Standard Operating Procedures (SOPs), Service Level Agreements (SLAs), and maintaining timely communication with clients and providers
• Compare reimbursement findings against applicable plan documentation, network agreements, and contract requirements for in‑ and out‑of‑network appeals
• Calculate and propose initial settlement offers based on claim history, other pricing tools, and relevant data
• Complete agreement templates detailing negotiated terms and forward them to providers for review
• Support compliance with ERISA and applicable federal and state regulations
• Maintain detailed documentation of appeal research, negotiations, approvals, and outcomes
• Record and document finalized agreements for future reference and compliance
• Ensure claims are priced accurately, reflecting the terms stipulated in finalized agreements
• Communicate regularly with clients to provide updates on appeal statuses, outcomes, and other pertinent information
• Prepare and issue denial determinations based on appeal reviews, ensuring compliance with applicable policies and guidelines
• Coordinate with clients when approvals exceed delegated authority in accordance with established policies and standard processes
• Utilize Zendesk, internal claims systems, Microsoft Outlook, Microsoft Teams, and other departmental software to manage appeals, documentation, and communication
• Perform other duties as assigned

Requirements

• 2+ years of healthcare claims, provider appeals, reimbursement, revenue cycle, or medical billing experience
• Knowledge of CPT‑4, HCPCS, Revenue Codes, DRG, and ICD‑10 coding for accurate claims review, pricing, and payment validation
• Knowledge of the No Surprise Act, ERISA guidelines, and related legislation
• Highly detail‑oriented with the ability to identify discrepancies and ensure accurate results
• Proficient in analyzing out‑of‑network claim appeals, utilizing claim pricing tools and data to assess reimbursement accuracy and support appeal determinations
• Knowledgeable of Medicare reimbursement methodologies
• Proficient in reviewing Explanation of Benefits (EOBs) to identify payment discrepancies and support claim appeal resolution
• Ability to interpret contracts and Plan documents to support accurate claim adjudication and appeal determinations
• Experienced in provider negotiations and evaluating counter offers to achieve timely and cost‑effective claim settlements
• Proficient in Microsoft Outlook, Teams, and