Appeal Resolution Specialist II
Appeal Resolution Specialist II 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 II 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 II 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 II occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be an Appeal Resolution Specialist II typically requires 2-4 years of related experience.
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