Appeal Resolution Specialist III

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Appeal Resolution Specialist III reviews and resolves claim appeals and grievances to determine appropriate outcomes in accordance with policy provisions and regulations. Investigates disputed claims by analyzing documentation, policy terms, and supporting evidence. Being an Appeal Resolution Specialist III coordinates with examiners, clinical staff, and other departments to gather information needed for determinations. Prepares clear written responses and determination letters that explain decisions and rationale. Additionally, Appeal Resolution Specialist III documents appeal activity and outcomes accurately within established timelines and systems. Ensures compliance with applicable regulations, accreditation standards, and company policies. Typically requires a bachelor's degree. Typically reports to a manager. The Appeal Resolution Specialist III work is generally independent and collaborative in nature. Contributes to moderately complex aspects of a project. To be an Appeal Resolution Specialist III typically requires 4-7 years of related experience.