Member Appeals Specialist in Boston, Massachusetts - #71591 | VanderHouwen

Description

Job Id: 71591

Member Appeals Specialist
Our client is seeking a Member Appeals Specialist to support the accurate and timely handling of member-initiated appeals and grievances within a highly regulated, system-driven environment. This role is ideal for a detail-oriented professional who exercises sound judgment, communicates clearly, and is comfortable making coverage-related determinations based on established policies and documentation. The successful candidate thrives in structured workflows, manages sensitive interactions with professionalism, and works effectively within a fully remote team.

This role is fully remote.

Member Appeals Specialist Responsibilities

• Manage assigned member appeals and grievances from intake through final resolution while meeting regulatory and internal turnaround requirements.
• Review cases for eligibility, completeness, and timeliness, determining appropriate actions based on established guidelines.
• Analyze documentation and available information to support coverage-related determinations and next steps.
• Prepare, edit, and issue required correspondence, including acknowledgements and determination notices, using approved templates.
• Identify missing or inconsistent information and initiate appropriate outreach to obtain necessary materials or clarification.
• Conduct outbound communication with members or authorized representatives in a clear, professional, and empathetic manner.
• Triage, categorize, and route incoming appeals or grievances to ensure proper workflow alignment.
• Maintain accurate, thorough, and audit-ready documentation within the system of record.
• Collaborate with internal stakeholders, including clinical and operational partners, to support case progression.
• Utilize multiple systems, tools, and communication channels to complete daily responsibilities.

Member Appeals Specialist Qualifications

• Prior experience handling member-side appeals within an insurance or managed care environment is required.
• Experience focused solely on provider appeals or denial responses is not sufficient for this role.
• MCO or payer-side experience involving determinations or case analysis is strongly preferred.
• Demonstrated ability to interpret and apply policies, guidelines, and structured workflows.
• Strong written communication skills, including the ability to finalize templated correspondence with accuracy.
• Comfortable conducting outbound member communication with professionalism and discretion.
• High attention to detail with consistent accuracy in documentation and case handling.
• Ability to manage a structured caseload in a compliance-driven environment.
• Proficiency working across multiple systems and operational tools.
• Reliable, self-directed, and effective in a remote work setting.

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
What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we’re in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies’ staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.

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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