Appeals Specialist Jobs
Appeals Specialist jobs are open across insurance, healthcare, government agencies, and financial services, from entry-level to senior and lead roles, with specializations in insurance claims appeals, healthcare billing disputes, and administrative law. Find a role that fits below and apply directly.
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Showing 5 of 23+ Appeals Specialist jobs
INTRODUCTION
Resolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines – Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health. Ensures regulatory compliance, timeliness requirements and accuracy standards are met. Coordinates efficient functioning of day-to-day operations according to defined processes and procedures. Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Assists with collecting and reporting data. Works under general supervision.
ROLE AND RESPONSIBILITIES
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Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements.
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Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems, focusing primarily on issues of medical necessity, quality of care, long term services and supports, etc. Consults with the member, family, providers and health plan departments as necessary. Identifies and communicates key points from details.
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Investigates and coordinates the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, accurate and timely follow up is completed and activities are documented as required.
-
Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan’s fiduciary responsibilities. Prepares records for physician review as needed.
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Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements.
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Coordinates external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations.
-
Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals. Consults with enrollees, providers and the Medical Director, as appropriate.
-
Provides input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service.
-
Reviews information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria.
-
Enters data and assists with compiling reports and analysis on the grievance and appeals process.
-
Participates in special projects and performs other duties as assigned.
BASIC QUALIFICATIONS
Licenses and Certifications:
- License and current registration to practice as a registered professional nurse in New York State required
Education:
- Bachelor's Degree or Master’s Degree in Nursing preferred
Work Experience:
-
Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management required
-
Proficient verbal/written communication skills required
-
Proficient computer and typing skills and knowledge of Microsoft Office (Word and Excel) required
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Ability to work in a fast paced environment and effectively manage multiple grievances and appeals simultaneously.
PAY RANGE
- USD $93,400.00 - USD $116,800.00 /Yr.
About us
VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We’re one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.
INTRODUCTION
Resolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines – Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health. Ensures regulatory compliance, timeliness requirements and accuracy standards are met. Coordinates efficient functioning of day-to-day operations according to defined processes and procedures. Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Assists with collecting and reporting data. Works under general supervision.
ROLE AND RESPONSIBILITIES
-
Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements.
-
Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems, focusing primarily on issues of medical necessity, quality of care, long term services and supports, etc. Consults with the member, family, providers and health plan departments as necessary. Identifies and communicates key points from details.
-
Investigates and coordinates the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, accurate and timely follow up is completed and activities are documented as required.
-
Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan’s fiduciary responsibilities. Prepares records for physician review as needed.
-
Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements.
-
Coordinates external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations.
-
Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals. Consults with enrollees, providers and the Medical Director, as appropriate.
-
Provides input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service.
-
Reviews information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria.
-
Enters data and assists with compiling reports and analysis on the grievance and appeals process.
-
Participates in special projects and performs other duties as assigned.
BASIC QUALIFICATIONS
Licenses and Certifications:
- License and current registration to practice as a registered professional nurse in New York State required
Education:
- Bachelor's Degree or Master’s Degree in Nursing preferred
Work Experience:
-
Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management required
-
Proficient verbal/written communication skills required
-
Proficient computer and typing skills and knowledge of Microsoft Office (Word and Excel) required
-
Ability to work in a fast paced environment and effectively manage multiple grievances and appeals simultaneously.
PAY RANGE
- USD $93,400.00 - USD $116,800.00 /Yr.
About us
VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We’re one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.
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Find Appeals Specialist JobsAppeals Specialist Job Market
Who's Hiring
Top Industries Hiring
- Healthcare & Medical Services
What Employers Look For
The qualifications that appear most often in appeals specialist jobs.
- Two or more years of experience reviewing or processing insurance, medical, or administrative claims
- Working knowledge of medical billing codes such as ICD-10 and CPT for healthcare appeals roles
- Strong written communication skills for drafting formal appeal letters and case summaries
- Familiarity with appeals regulations including Medicare, Medicaid, or state insurance department guidelines
- Proficiency with claims management or case management software platforms
- Associate or bachelor's degree in healthcare administration, business, paralegal studies, or a related field
Tips for Your Appeals Specialist Job Search
Tailor your resume to denial language
Appeals specialists are hired to reverse unfavorable decisions, so your resume needs to show outcomes, not just duties. Quantify the types of denials you handled and the resolution rate you achieved across claim categories or case types.
Highlight regulatory and compliance knowledge
Employers in insurance and healthcare want specialists who know the rules driving denials. Call out specific regulations you've worked under, whether that's state insurance codes, Medicare coverage guidelines, or federal administrative procedures, directly in your work history.
Apply early to roles that fit
Migrate Mate lists appeals specialist openings from across the United States in one place, so you can find roles that match your background and apply directly to each listing without sorting through unrelated postings.
Search by the denial type you specialize in
Appeals roles are segmented tightly by domain. Search for terms like 'clinical appeals,' 'prior authorization appeals,' or 'disability claims review' rather than just 'appeals specialist' to surface openings that match your exact experience instead of generic administrative roles.
Prepare a case-reversal example for interviews
Interviewers will almost always ask you to walk through a denial you successfully overturned. Have a specific example ready that covers the original decision, the evidence or argument you used, and the outcome, without disclosing confidential client details.
Negotiate with documentation turnaround in mind
When evaluating an offer, ask about average caseload volume and documentation systems in use. Specialists handling high-volume queues in outdated systems often face burnout quickly, and knowing this upfront lets you negotiate for realistic workload expectations before you accept.
Appeals Specialist Jobs: Frequently Asked Questions
Which companies are hiring the most appeals specialists?
The companies hiring the most appeals specialists right now include Northwest Administrators, VNS Health, and Caromont, with the largest share of openings in Texas, New York, and Washington, based on current listings on Migrate Mate as of November 2026. Insurance carriers, managed care organizations, and third-party administrators consistently represent the largest share of active postings.
How many appeals specialist jobs are remote?
About 59% of appeals specialist openings are fully remote or hybrid as of November 2026, reflecting strong employer flexibility for roles that center on document review and written case work. Fully remote positions are most common in insurance claims appeals and healthcare utilization management, where case files are handled entirely through digital platforms.
How do you become an appeals specialist?
Start by building experience in a related administrative or claims role, such as a claims examiner, billing specialist, or customer service representative at an insurance company or healthcare organization. From there, deepen your knowledge of the specific regulatory framework governing the denials you want to review. Earning a certification in healthcare billing or completing paralegal coursework strengthens your application for appeals roles in those sectors.
Can you get an appeals specialist job with little or no experience?
Entry-level appeals roles do exist, particularly at insurance carriers and third-party administrators that hire candidates with strong written communication skills and train them on internal appeals procedures. If you're starting with no direct experience, focus on roles titled 'claims reviewer' or 'appeals coordinator' rather than senior specialist positions, and emphasize any background in customer dispute resolution, medical billing, or administrative decision-making.
What does the appeals specialist interview process look like?
Most appeals specialist interviews involve an initial phone or video screen with HR, followed by a panel or one-on-one interview with a team lead or operations manager. Interviewers typically ask you to walk through a past case you reviewed, test your familiarity with relevant regulations, and assess your written communication by reviewing a sample denial letter or asking you to draft a short appeal summary on the spot.
Where can I find and apply to appeals specialist jobs?
You can find and apply to appeals specialist jobs on Migrate Mate, which lists current openings from across the United States in one place. Find roles that match your background and apply directly to each listing without having to sort through unrelated results or navigate multiple separate employer sites.
See All 23 Appeals Specialist Jobs
Find roles that match your experience and apply in just a few clicks.
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