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Appeals Specialist I

Spectraforce Technologies
United States, Tennessee, Nashville
Jun 27, 2025
Job Title: Appeals Specialist I

Duration: 5+ Months

Location: Remote

Shift: M-F 9am-6pm CST with 1 hour lunch

Basic function:

Under supervision, this position is responsible for processing, organizing, and coordinating all materials and information relating to processing appeals for all lines of business following federal, state, and accreditation requirements; and for accurately responding by telephone, in person, or through correspondence to all inquiries involving requests for appeals from members, the Department of Labor, or ERISA; sending acknowledgement letter to member and draft provider letters for directors' signature; entry of appeals into appropriate database; and processing of internal quality of care referrals.

Essential functions:

  • Complete, organize and oversee the appeal process of the unit to ensure all telephone and written appeals are processed accurately and promptly.
  • Coordinate all appeal functions which involves preparing summary reports; categorizing and routing medical appeals to the appropriate departments for action and acting as the liaison with other units regarding appeal issues.
  • Accurately respond by telephone, in person, or through correspondence to all inquiries involving requests for appeals
  • Determine need for obtaining additional information and notifying members and/or providers as related to the processing of appeals.
  • Respond to appeal requests within designated time requirements.
  • Acknowledge member complaints within the regulatory timeframe.
  • Compose letter to provider for management approval, track timeliness of response, and send follow-up letters as appropriate.
  • Coordinate internal quality of care referral.
  • Promote goodwill of our customer population through capable, efficient, caring, and composed performance.
  • Coordinate and maintain system of tracking member complaints and appeals which includes identification and resolution of member concerns or outcome of appeal or internal quality of care referral.
  • Provider support to supervisor, and appeals RN, and grievance coordinator as necessary.
  • Identify trends and communicate this information to the supervisor.
  • Communicate and interact effectively and professionally with co-workers, management, customers, etc.
  • Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
  • Maintain complete confidentiality of company business.
  • Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.



Job requirements:

  • 2 years' experience researching and responding to telephone and / or correspondence inquiries regarding health insurance claims/services OR 1 year health insurance plus 2 years of customer service experience.
  • Effective analytical, problem solving and research skills.
  • Effective organizational skills to accommodate large volume of reference materials combined with time management skills to achieve accessibility to callers.
  • Effective verbal and written communication skills to include the ability to clearly express oneself in a well-modulated tone with correct grammar and attention to enunciation.



Preferred Job Requirements:

  • BlueChip claims payment experience.
  • Medical terminology.
  • Knowledge of appeals processing.
  • Ability to think clearly and maintain a professional, poised attitude under pressure.
  • Detail oriented.
  • Bi-lingual Spanish speaking.

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