Member Appeals Specialist in Boston, Massachusetts - #72222 | VanderHouwen

Description

Job Id: 72222

Member Appeals Specialist
Our client is seeking a Member Appeals Specialist to support a high-volume appeals and grievances function within a regulated healthcare environment. This role is ideal for someone who thrives in a structured, process-driven setting, can manage multiple cases simultaneously, and communicates effectively across teams while ensuring compliance and accuracy. The ideal candidate brings strong attention to detail, accountability, and the ability to navigate systems and workflows with confidence in a fully remote environment.

This role is fully remote.

Member Appeals Specialist Responsibilities

• Manage the full lifecycle of member appeals, from assignment through resolution, ensuring adherence to regulatory timelines and internal standards.
• Triage incoming appeals and grievances, accurately categorize cases, and assign or route work as appropriate.
• Review appeal requests to assess eligibility, timeliness, and completeness, identifying when additional documentation or authorizations are required.
• Draft and issue acknowledgment and determination letters using standardized templates, ensuring accuracy and compliance with guidelines.
• Conduct outbound communication with members, providers, or representatives to gather information and resolve outstanding items.
• Maintain and prioritize a caseload of approximately 40 active cases, meeting standard and expedited turnaround requirements.
• Collaborate cross-functionally with internal stakeholders, including clinical reviewers, leadership, and support teams, to progress cases efficiently.
• Utilize multiple systems and tools to document, track, and process appeals, ensuring all actions are accurately recorded.

Member Appeals Specialist Qualifications

• 2+ years of experience handling member appeals within a healthcare or health plan environment.
• Demonstrated experience managing appeals cases end-to-end within a case management or appeals system.
• Strong understanding of regulatory timelines, compliance requirements, and documentation standards related to appeals and grievances.
• Excellent written communication skills, with experience drafting professional correspondence using templates and adapting language as needed.
• Ability to manage a high-volume caseload while maintaining accuracy, organization, and attention to detail.
• Comfortable navigating multiple systems and tools in a remote work environment, including case management and communication platforms.
• Strong interpersonal skills with a collaborative mindset and willingness to seek guidance when needed.
• Reliable, responsive, and self-motivated, with a commitment to delivering high-quality, compliant work.

Compensation: $20-$22/hr. (DOE)

VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
As an eligible contract employee with VanderHouwen, you’ll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

Meet VanderHouwen
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VanderHouwen is an award-winning, Women & Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!

VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.

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