Medical Appeals Representative

Medical Appeals Representative Location:

Baton Rouge, LA (Main Campus)

Work Arrangement:

100%

Onsite Pay Rate:

$25/hr Position Summary The Medical Appeals Representative provides operational support for the intake, review, prioritization, and coordination of medical appeals to ensure timely and compliant processing. This role performs initial assessment of incoming appeals, distinguishes between expedited and standard requests, and facilitates accurate routing to clinical staff. The ideal candidate is highly organized, detail-oriented, and capable of working independently in a fast-paced healthcare environment while maintaining compliance with HIPAA and regulatory requirements. Key Responsibilities Review incoming appeal requests received via mail, fax, and electronic submission channels. Determine appeal eligibility and accurately classify cases as expedited or standard based on regulatory requirements. Establish and maintain appeal cases within designated systems, including EPIC. Prioritize, organize, distribute, and track appeals to appropriate clinical staff. Monitor appeal workflows to ensure compliance with service level agreements and regulatory deadlines. Conduct research and prepare supporting documentation for appeal processing. Assist Medical Appeals Specialists with case setup, routing, and processing during periods of high volume or staff absence. Maintain accurate case records and documentation in accordance with audit and retention requirements. Ensure compliance with HIPAA, PPACA, Department of Insurance (DOI), URAC, and other applicable regulations. Collaborate with internal departments to facilitate resolution and support operational compliance. Identify workflow improvement opportunities and communicate recommendations to leadership. Perform additional duties as assigned. Qualifications Education High School Diploma or GED required. Experience Minimum 3 years of insurance experience, including benefits and claims research. Minimum 2 years of customer service and/or claims processing experience. Experience may be concurrent. Experience with Facets is preferred. Required Knowledge, Skills & Abilities Knowledge of health insurance benefits and claims processing procedures. Ability to interpret benefit plans across multiple lines of business. Familiarity with CPT, ICD-10, and HCPCS coding systems. Understanding of healthcare regulations, accreditation standards, and appeals processes. Strong organizational, prioritization, and time management skills. Exceptional attention to detail and accuracy. Ability to work independently and manage competing priorities. Strong written and verbal communication skills. Proficiency with Microsoft Office applications, including Word and Excel. Preferred Systems Experience EPIC Facets ESI Provider Portal Common Query Adobe Standard Work Environment 100% onsite at Baton Rouge, LA Standard office environment. High-volume, deadline-driven workload requiring strong prioritization and independent decision-making. Flexibility to support team coverage and changing business needs.