CW Appeals Specialist

We are looking for a detail-oriented CW Appeals Specialist to support a health insurance organization on a Contract basis. This role focuses on investigating complaints, grievances, and appeal-related concerns submitted by members, providers, legal representatives, and regulatory bodies while ensuring timely and accurate resolution. The position is fully remote, offering an opportunity to contribute in a fast-paced, high-volume environment where accuracy and clear communication are essential. Must be willing to work Pacific Time Zone hours.

Responsibilities:

• Investigate appeal cases, complaints, and grievance matters by gathering information from claims records, eligibility details, benefit plans, contracts, and prior case activity.
• Respond to concerns raised by members, providers, attorneys, and government agencies with clear, well-supported resolutions based on policy, contract terms, and applicable regulations.
• Maintain complete and accurate case documentation, ensuring all actions, findings, and outcomes are recorded properly for tracking and reporting purposes.
• Review system data and supporting files to identify inconsistencies, update records when corrections are needed, and help preserve data accuracy.
• Evaluate dispute issues within assigned authority levels and make determinations on contractual matters in accordance with established guidelines.
• Interpret member and provider contract language to assess appeal circumstances and apply benefit provisions appropriately to each case.
• Monitor recurring issue patterns, summarize findings, and communicate trends or potential defects to leadership for further review.
• Partner with customer service and internal support teams to address referred cases and resolve complex service concerns efficiently.
• Consistently meet productivity and quality expectations while managing a steady workload in a high-production environment.
• Prior experience in health plan operations, ideally in appeals, grievances, claims, or complaint resolution.
• Hands-on experience using Facets is strongly preferred.
• Ability to work effectively in a high-volume setting while maintaining accuracy, organization, and timeliness.
• Working knowledge of health insurance benefits, claims administration, and contract interpretation.
• Strong written and verbal communication skills with the ability to correspond professionally with internal and external parties.
• Experience handling sensitive issues involving members, providers, legal entities, or regulatory agencies.
• Proficiency with databases, reporting tools, and case documentation practices.
• Ability to collaborate across teams and exercise sound judgment when resolving complex issues.