Appeals Professional in United States at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for an Appeals Professional based in the United States.

This role is focused on conducting detailed, evidence-based reviews of complex healthcare appeals and dispute cases within a federal program environment. You will serve as an independent decision-maker responsible for evaluating medical records, regulatory guidance, and policy documentation to determine the validity of appeals related to enrollment denials, suspensions, or revocations. The position requires strong analytical judgment, attention to detail, and the ability to interpret complex healthcare regulations with accuracy and fairness. You will be expected to produce clear, well-reasoned determinations that are fully supported by evidence and compliant with federal guidelines. Operating in a remote and structured environment, you will collaborate indirectly with providers, beneficiaries, and stakeholders while maintaining impartiality and consistency in decision-making. This is a highly responsible role suited for professionals who thrive in research-heavy, policy-driven healthcare settings.

• Review complex appeal cases, including medical records and supporting documentation, to determine whether enrollment denials, suspensions, or revocations should be upheld or overturned.
• Issue clear, concise, and well-supported written determinations based on medical evidence, regulatory standards, and applicable policies.
• Conduct in-depth research using federal regulations, medical literature, contract manuals, and coverage guidelines to ensure accurate and compliant decisions.
• Ensure all issues raised by beneficiaries, providers, and representatives are fully addressed in each case review.
• Apply independent judgment to interpret statutes, policies, and clinical evidence in order to reach fair and impartial decisions.
• Participate in quality reviews, audits, and special projects to support continuous improvement of the appeals process.
• Stay current on evolving healthcare regulations, medical practices, and policy updates relevant to Medicare appeals.

This role requires a healthcare professional with strong experience in medical review, appeals, or dispute resolution, along with deep knowledge of Medicare processes and regulatory frameworks. The ideal candidate is highly analytical, detail-oriented, and capable of making independent, well-reasoned decisions in a structured and compliance-driven environment.

• Minimum of 3 years of experience in Medicare appeals, medical review, clinical work, or healthcare-related dispute resolution.
• Strong knowledge of Medicare regulations, claims administration, coverage rules, and federal healthcare policies.
• Ability to research and interpret medical terminology, healthcare guidelines, and state/federal regulations accurately.
• Excellent written communication skills with strong grammar, clarity, and attention to detail in documentation.
• Strong analytical and critical thinking skills with the ability to draw logical conclusions from complex information.
• Proven ability to manage multiple priorities, meet deadlines, and work independently under general supervision.
• High level of integrity, professionalism, and commitment to confidentiality and ethical standards.
• Experience with Medicare managed care appeals is preferred.
• Associate’s degree or equivalent healthcare-related education/experience required.
• Must meet federal residency and authorization requirements and be eligible to obtain a Public Trust or equivalent clearance.

• Fully remote work arrangement anywhere within the United States
• Opportunity to work on federally regulated, high-impact healthcare programs
• Competitive compensation package (based on experience)
• Professional development in healthcare policy and appeals processes
• Exposure to complex regulatory and clinical decision-making work
• Standard benefits package (health, dental, vision, and retirement options, where applicable)
• Paid time off and holiday eligibility