Appeals Examiner- Healthcare

Position Overview

The Appeals Examiner plays a critical role in managing and processing provider reconsiderations and appeals with the highest levels of accuracy and compliance. Working within a dynamic team environment at Wipro Limited, you will ensure integrity in benefit plan interpretation, foster positive relationships with providers and members, and contribute to continuous improvements in operational workflows.

Key Responsibilities

• Coordinate comprehensive review and resolution of member appeals and provider disputes in compliance with Department of Labor regulations and client-specific service level agreements (SLAs).
• Meticulously document all case actions and outcomes for auditing and quality assurance purposes.
• Collaborate with internal teams, including medical review and adjustment departments, to facilitate escalations and timely resolution of complex cases.
• Interpret Summary Plan Documents to determine appeal validity and formulate appropriate responses.
• Ensure strict adherence to HIPAA and privacy guidelines in handling confidential member and provider information.
• Communicate clearly with providers, members, and stakeholders regarding appeal decisions and next steps.
• Assist in researching and responding to member complaints, working collaboratively with internal departments and external contacts.
• Support continuous process improvement by recommending enhancements during team meetings and training sessions.
• Perform additional duties as assigned to contribute to the overall success of the appeals and grievance department.

Required Qualifications

• High School diploma or GED equivalent; additional education or certifications in healthcare administration or insurance processes are a plus.
• Proven problem-solving abilities with a focus on interpreting benefit plans and related documentation accurately.
• Working knowledge or familiarity with healthcare coding systems (such as CPT and ICD-9/ICD-10) and medical terminology is strongly preferred.
• Ability to work effectively with minimal supervision while managing multiple priorities in a fast-paced environment.
• Proficiency in standard computer applications (Microsoft Office Suite) and experience with specialized claims or case management software.
• Demonstrated average to above-average typing skills to ensure efficient data entry and documentation.
• Excellent interpersonal and communication skills for professional interaction with members, providers, and team members.
• A strong commitment to confidentiality, accuracy, and compliance with regulatory standards.

Benefits & Perks

• Compensation: $40,000 to $44,000 per year. Final compensation depends on location, applicable wage obligations, skills, and relevant experience.
• Benefits: Eligible for Wipro’s standard benefits, including a full range of medical and dental options, disability insurance, paid time off (inclusive of sick leave), as well as other paid and unpaid leave options.
• Employment may be conditioned on a post-offer drug screening, subject to applicable state law.