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Robert Half Denials Specialist in Los Angeles, California


A health plan in the Mid-Wilshire area is in need of an Appeals Coordinator on a Contract to Hire Basis. The Appeals Coordinator MUST work 100% onsite in the office in Mid-Wilshire.

The Appeals Coordinator is responsible for the investigation, documentation and resolution of participant appeals in compliance with State/Federal law, rules, and guidelines. The Appeals Coordinator will perform research and utilize extensive claims knowledge to respond to inquiries and interpret plan/policy provisions.

This position interacts with the Health Plan staff, Plan participants, business managers, health care providers, medical insurance companies and related governmental agencies, and medical consultants. In addition to daily interaction with the Department Manager and Assistant Manager, this position also interacts with Executive Management whenever necessary.


Work independently using discretion and independent judgment under the general supervision of the department manager and within broad parameters of policy established by management:

· Conduct research to advise management on medical claims issues and develop guidelines for use by the examiners or Participant Services Representatives when necessary.

· Research correspondence and appeals submitted by participants and providers.

· Manage documentation and correspondence for all appeals cases.

· Prepare and write appeals cases and present to the Benefit Committee.

· Coordinate reviews regarding the medical necessity of services with the Health Plan’s medical consultants. Write determination letters regarding the outcome of the reviews and send to the applicable participant/provider.


  • Comprehensive knowledge of medical appeals

  • Prior experience in denials management is preferred

  • Knowledge of insurance regulations and policies, payment policies/guidelines and the ability to communicate and work with payers to get claims resolved and paid accurately desired

  • Minimum of at least 2-3 years of experience within the revenue cycle

  • Strong understanding of explanation of benefits (EOBs)

  • Medical claims experience preferred

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