Appeals Analyst

Vālenz Health® is the destination for employers, brokers, payers, and providers to reduce costs, improve quality, and elevate the healthcare experience. Through advanced technology and clinical expertise, Valenz creates a distinctly different approach to a complex healthcare system. With our solutions, we execute across the entire healthcare journey — from member experience to payment integrity, provider quality, and plan performance.  With one of America’s largest cost, quality and utilization datasets, we create greater transparency, flexibility, and cost containment — empowering members and employers with the information they need to make smarter, more cost-effective decisions.

About This Opportunity:
As an Appeals Analyst, you’ll review provider appeals by applying established procedures, service level agreements, plan documents, and network contract requirements to ensure accurate and timely claim determinations. You’ll calculate and negotiate settlement offers, prepare agreement documentation, issue denial determinations when appropriate, and coordinate approvals that exceed delegated authority while maintaining compliance with ERISA and applicable federal and state regulations. You’ll also maintain detailed records of appeal activity and outcomes, ensure claims are priced according to finalized terms, communicate statuses and resolutions with clients and providers, and utilize Zendesk, internal claims systems, Microsoft Outlook, and Microsoft Teams to support efficient case management and workflow.

Things You’ll Do Here :

- Review appeals received from providers while adhering to established Standard Operating Procedures (SOPs), Service Level Agreements (SLAs), and maintaining timely communication with clients and providers.
- Compare reimbursement findings against applicable plan documentation, network agreements, and contract requirements for in- and out-of-network appeals.
- Calculate and propose initial settlement offers based on claim history, other pricing tools, and relevant data.
- Complete agreement templates detailing negotiated terms and forward them to providers for review.
- Support compliance with ERISA and applicable federal and state regulations.
- Maintain detailed documentation of appeal research, negotiations, approvals, and outcomes.
- Record and document finalized agreements for future reference and compliance.
- Ensure claims are priced accurately, reflecting the terms stipulated in finalized agreements.
- Communicate regularly with clients to provide updates on appeal statuses, outcomes, and other pertinent information.
- Prepare and issue denial determinations based on appeal reviews, ensuring compliance with applicable policies and guidelines.
- Coordinate with clients when approvals exceed delegated authority in accordance with established policies and standard processes.
- Utilize Zendesk, internal claims systems, Microsoft Outlook, Microsoft Teams, and other departmental software to manage appeals, documentation, and communication.
- Perform other duties as assigned.
Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

What You’ll Bring to the Team :
- 2+  years of healthcare claims, provider appeals, reimbursement, revenue cycle, or medical billing experience.
- Knowledgeable in of CPT-4, HCPCS, Revenue Codes, DRG, and ICD-10 coding for accurate claims review, pricing, and payment validation.
- Knowledge of the No Surprise Act, ERISA guidelines, and related legislation.
- Highly detail-oriented with the ability to identify discrepancies and ensure accurate results
- Proficient in analyzing out-of-network claim appeals, utilizing claim pricing tools and data to assess reimbursement accuracy and support appeal determinations.
- Knowledgeable of Medicare reimbursement methodologies
- Proficient in reviewing Explanation of Benefits (EOBs) to identify payment discrepancies and support claim appeal resolution.
- Ability to interpret contracts and Plan documents to support accurate claim adjudication and appeal determinations.
- Experienced in provider negotiations and evaluated counter offers to achieve timely and cost-effective claim settlements.
- Experience with Microsoft Outlook, Teams, and Excel
- Dependable and committed to maintaining a reliable work schedule while meeting productivity and performance expectations.

A plus if you have…
- Associate or bachelor’s degree in healthcare administration, or related field.
- CPC Certification
- Experience with international plans and self-funded insurance.
- Knowledge of Independent Dispute Resolution (IDR) process, including applicable reimbursement guidelines and compliance requirements.

Where You’ll Work: This is a fully remote position, and we’ll provide all the necessary equipment!

- Work Environment: You’ll need a quiet workspace that is free from distractions.
- Technology: Reliable internet connection—if you can use streaming services, you’re good to go!
- Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software.
- Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA.
 
Why You'll Love Working Here

Our mission is to advance healthcare through technology and expertise to optimize cost, quality, access, and utilization for all. We bring that mission to life through our commitment to Collaboration, Performance, Transparency, and Trust—the core values that guide how we work with our members, our customers, and each other.

Benefits

- Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
- Spending account options: HSA, FSA, and DCFSA
- 401K with company match and immediate vesting
- Flexible working environment
- Generous Paid Time Off to include vacation, sick leave, and paid holidays
- Employee Assistance Program that includes professional counseling, referrals, and additional services
- Paid maternity and paternity leave
- Pet insurance
- Employee discounts on phone plans, car rentals and computers
- Community giveback opportunities, including paid time off for philanthropic endeavors

At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.