Workers' Compensation Appeal Specialist

Accountabilities:

• • Manage an assigned caseload of post-payment Workers' Compensation bills, including state balance-billing matters and usual-and-customary-rate (UCR) disputes.
  • Conduct proactive outreach to medical providers to explain payment methodologies, investigate disputed charges, and negotiate reductions on appealed or outlier bills.
  • Communicate professionally with clients to gather information, coordinate investigations, and support effective appeal resolution.
  • Educate providers on Workers' Compensation billing practices, reimbursement methodologies, applicable policies, and regulatory requirements.
  • Thoroughly document all provider interactions, including contact details, bill information, proposed and counter-offered payment rates, and final outcomes.
  • Ensure all case activities comply with state-specific Workers' Compensation regulations, confidentiality standards, and HIPAA requirements.
  • Maintain productivity and quality standards while resolving cases within applicable regulatory and client-specific timelines.
  • Follow established client protocols, internal procedures, communication scripts, and documentation requirements.
  • Monitor changes to Workers' Compensation regulations, fee schedules, reimbursement policies, and state-specific requirements across multiple jurisdictions.
  • Collaborate effectively with internal team members and contribute to a positive, results-oriented team environment.
  • Support special projects and take on additional responsibilities as needed.

  Requirements:

  • 2–3 years of relevant experience working with Workers' Compensation bills, medical billing, medical coding, insurance negotiations, or a closely related field.
  • Strong understanding of Workers' Compensation reimbursement methodologies, state regulations, fee schedules, and provider billing practices.
  • Demonstrated experience negotiating medical bill payments, adjustments, reductions, or disputed charges with healthcare providers.
  • Familiarity with claims processing systems and provider-facing communications.
  • Strong verbal and written communication skills, with the ability to explain complex billing and reimbursement matters clearly and professionally.
  • Excellent negotiation, organization, prioritization, and case-management skills.
  • Strong attention to detail and the ability to maintain accurate documentation across multiple cases.
  • Sound judgment and decision-making skills, with the ability to evaluate information and determine appropriate next steps.
  • Ability to collaborate effectively with a variety of internal and external stakeholders.
  • High level of discretion, professionalism, and ethical conduct when handling confidential healthcare and claims information.
  • Comfortable working in a structured, deadline-driven environment while maintaining productivity and quality standards.
  • Strong technical aptitude and the ability to learn and navigate claims, billing, and other business systems.

  Benefits:

  • Salary: $55,000–$65,000 USD annually, with compensation based on experience and qualifications.
  • Certain positions may offer additional compensation opportunities, including bonuses and merit increases.
  • Comprehensive medical, dental, vision, and life insurance coverage.
  • 401(k) retirement plan with employer matching.
  • Health Savings Account (HSA) and Flexible Spending Accounts (FSAs).
  • Paid time off (PTO) and disability leave.
  • Employee Assistance Program (EAP) providing additional support and resources.
  • Inclusive workplace committed to equal employment opportunity and respect for diverse backgrounds and perspectives.