Member Appeals Specialist in Boston, Massachusetts - #72857 | VanderHouwen

Description

Job Id: 72857

Member Appeals Specialist
Our client is seeking a Member Appeals Specialist to join a collaborative, fully remote team supporting member-focused healthcare operations. This role is ideal for a detail-oriented professional who thrives in a structured, compliance-driven environment, enjoys managing cases from start to finish, and is committed to delivering exceptional service while meeting regulatory deadlines.

This role is fully remote.

Member Appeals Specialist Responsibilities

• Manage member appeal cases from initial assignment through final resolution, ensuring all regulatory and internal turnaround requirements are met.
• Review and triage incoming appeals, verify member eligibility and timeliness, determine next steps, and identify any additional documentation required to support case processing.
• Prepare, customize, and issue required member correspondence using approved templates while maintaining compliance with established policies and regulatory guidelines.
• Communicate professionally with members and internal stakeholders by phone, email, voicemail, and other communication channels to gather information, answer questions, and resolve outstanding items.
• Collaborate with cross-functional teams, including clinical, pharmacy, quality, and leadership partners, to ensure accurate and timely case progression.
• Draft appeal determination notices using established reference materials and approved language to support consistent, compliant decision-making.
• Maintain an active caseload while accurately documenting activity within multiple healthcare systems and ensuring all case records remain complete and up to date.
• Monitor shared communication channels, including email inboxes and voicemail, and assist with intake, categorization, and assignment of incoming appeals and grievances.

Member Appeals Specialist Qualifications

• Experience managing member appeals within a health insurance or managed care environment, including ownership of cases from intake through resolution.
• Working knowledge of healthcare appeals, grievance processes, regulatory timelines, and documentation requirements.
• Experience utilizing case management or appeals systems, along with multiple business applications, to process and track work efficiently.
• Strong written and verbal communication skills with the ability to produce professional correspondence and provide outstanding member service.
• Exceptional organizational skills with the ability to manage a high-volume caseload while maintaining accuracy and attention to detail.
• Demonstrated ability to work independently in a fully remote environment while collaborating effectively with cross-functional teams.
• Comfortable learning new systems, reference materials, and established workflows to ensure consistency and compliance.
• Experience supporting pharmacy or healthcare benefit operations is preferred.

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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