Appeals Specialist

Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market – to do more for clients – and take them beyond the standard “Point A to Point B.” We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as, network and payment integrity, pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company. We’re looking for a detail-oriented and motivated Appeals Specialist to join our team. In this role, you’ll review, research, and resolve healthcare claim appeals for accuracy and compliance with plan provisions, state and federal regulations, and internal procedures. Key Responsibilities Review incoming appeals to determine appropriate handling and next steps. Analyze claim determinations, plan documents, and supporting documentation to ensure decisions are accurate and compliant. Draft professional, well-supported appeal determinations and correspondence. Collaborate with internal teams (claims, eligibility, customer service, and provider relations) to gather information and resolve cases. Track and document all appeal activity in internal systems with accuracy and clarity. Identify patterns or process issues contributing to appeal volume and communicate findings to leadership. Support continuous improvement by suggesting updates to policies, templates, or workflows. Maintain confidentiality and compliance with HIPAA and company policies. Qualifications Required: Strong attention to detail and organizational skills. 1–2 years of experience in a healthcare or insurance environment. 1-2 years of experience working with appeals. Excellent written and verbal communication skills. Ability to analyze data and documentation logically and objectively. Experience reviewing and interpreting plan documents. Comfortable managing multiple priorities in a fast-paced environment. Proficiency in Microsoft Office (especially Excel and Outlook). Eagerness to learn the healthcare and TPA industry from the ground up. Preferred: Experience with medical, dental, or vision claim processing. Prior work at a TPA , health plan, or provider office. Familiarity with ERISA, state appeal timelines, or standard healthcare terminology (EOBs, CPT/ICD codes, etc.). Familiarity with the No Surprises Act. Familiarity with CMS terminology. Exposure to claim systems or workflow platforms. Individual compensation will be commensurate with the candidate's experience and qualifications. Certain roles may be eligible for additional compensation, including bonuses, and merit increases. Additionally, certain roles have the opportunity to receive sales commissions that are based on the terms of the sales commission plan applicable to the role. Pay Transparency $17 — $20 USD Benefits: Comprehensive medical, dental, vision, and life insurance coverage 401(k) retirement plan with employer match Health Savings Account (HSA) & Flexible Spending Accounts (FSAs) Paid time off (PTO) and disability leave Employee Assistance Program (EAP) Equal Employment Opportunity : At Point C Health, we know we are better together. We value, respect, and protect the uniqueness each of us brings. Innovation flourishes by including all voices and makes our business—and our society—stronger. Point C Health is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices, including selection, hiring, performance management, promotion, transfer, compensation, benefits, education, training, social, and recreational activities to all persons regardless of race, religious creed, color, national origin, ancestry, physical disability, mental disability, genetic information, pregnancy, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, and military and veteran status, or any other protected status protected by local, state or federal law.