Summary

The Appeals Examiner reviews, researches, and resolves healthcare provider appeals related to medical claims and payment determinations.

This role analyzes appeal documentation, researches claim payment issues, and ensures each appeal is reviewed accurately and completely in accordance with established guidelines, policies, and regulatory requirements. The ideal candidate brings strong medical claims or appeals experience, exceptional attention to detail, and the ability to consistently meet quality and productivity standards.

Your role in our mission

• Review and research provider appeals using established guidelines and document appeal determinations clearly, accurately, and concisely.
• Analyze medical claims, appeal documentation, payment information, and supporting records to ensure all aspects of an appeal have been appropriately addressed.
• Research and resolve claim payment issues, identifying discrepancies and determining appropriate actions based on established policies and procedures.
• Resubmit or adjust claims for approved appeals, ensuring appropriate claim corrections and supporting documentation are completed.
• Maintain established productivity, accuracy, and quality standards while managing assigned appeals through resolution.
• Protect confidential information and maintain compliance with HIPAA and applicable organizational and regulatory requirements.

What we're looking for

• Two or more years of medical claims and/or appeals experience required.
• Experience researching and resolving healthcare claim payment issues.
• Experience working with health insurance and medical terminology.
• Strong research, analytical, and problem-solving skills with exceptional attention to detail and accuracy.
• Ability to interpret claims information, appeal documentation, policies, and procedures to determine appropriate resolution.
• Ability to work effectively in a production-focused environment while meeting established quality and productivity expectations.
• Proficiency with Microsoft Outlook, Word, Excel, Teams, and related business systems.

What you should expect in this role

• This position requires working onsite in West Sacramento, California, for the first 90 days.

• After 90 days, employees may be eligible to transition to fully remote work (work from home), based on performance, productivity, quality standards, management approval, and business needs.

• Work schedule: 6:00 a.m. to 2:30 p.m. Pacific Time.

• Opportunity to support California's Medi-Cal program by ensuring provider appeals and medical claims are researched and resolved accurately and timely.

Applications for this position will be accepted through October 31, 2026.

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