Appeals Processor III - RN

Ghost RX

New York, New York, United States

New York, New York, United States

Über

We are seeking a highly skilled Appeals Processor III (APP III) to join our dedicated team in a remote capacity. The Appeals Processor III (APP III) is responsible for reviewing, analyzing, and processing healthcare appeals related to Medicaid or Medicare coverage decisions. This role ensures all cases are handled in compliance with federal/state regulations, CMS guidelines, and contract requirements.
Qualification and Requirements Requirements
Associate’s Degree (Bachelor’s preferred)
2+ years in:
Healthcare appeals
Medical claims / utilization review
Insurance or Medicaid/Medicare processing
Strong knowledge of:
CMS guidelines
Medicaid/Medicare (especially Part C)
Experience reviewing medical documentation (clinical roles may require RN)
Responsibilities Duties
Review incoming appeals, medical records, and supporting documentation
Analyze cases using state/federal regulations and CMS guidelines
Determine if additional documentation is required and request it when needed
Process appeals from start to finish, including final determinations
Decision Support & Documentation
Prepare case summaries and ensure files are complete for review
Draft or support writing determination/decision letters
Ensure all documentation meets quality and compliance standards
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New York, New York, United States

Sprachkenntnisse

English

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