Appeals Representative I

STAR Medical Auditing Services is a boutique consulting firm that provides Health Information Management (HIM) and Clinical services to various organizations in the healthcare ecosystem across the U.S. We pride ourselves in providing high-quality services that are tailored to our clients' specific needs, while creating joyful experiences along the way by treating everyone with respect and care.

Must reside and be legal to work in the U.S.

About the Role

We are seeking a detail-oriented Appeals Representative I to support our Medicare Administrative Contract (MAC). In this non-clinical role, you will be responsible for reviewing, analyzing, and processing non-complex pre-service and post-service grievance and appeal requests. This includes inquiries from Medicare beneficiaries, providers, regulatory bodies, and third parties across Part A and B services.

You'll play a key support role in ensuring compliance with CMS guidelines, contractual obligations, and internal quality standards—all while protecting sensitive data and working in a highly regulated environment.

How You'll Make an Impact

• Review and process non-clinical, non-complex appeals and grievances in accordance with CMS, MAC, and internal policies.
• Conduct case research using claims systems, CMS guidelines, and policy references.
• Draft clear, professional, and accurate written responses to communicate appeal determinations.
• Route clinical issues to RN or medical reviewers when appropriate.
• Ensure appeal files meet regulatory and timeliness requirements.
• Follow standardized operating procedures (SOPs), quality checklists, and documentation protocols.
• Maintain strict confidentiality and HIPAA compliance at all times.
• Serve as a liaison between appeals, claims, legal, medical management, and other internal departments.

This position does not involve utilization review or clinical decision-making.

Core Qualifications

Education:

• High school diploma or GED (required)
• Associate's or Bachelor's degree in Health Administration, Business, or related field (preferred)

Experience:

• 1–3 years of experience in healthcare claims, appeals, or medical billing/insurance processing
• Experience with Medicare/Medicaid regulations and provider appeals processes
• Prior work handling sensitive health data in compliance with HIPAA
• SCA/MAC environment experience is a strong plus

Knowledge & Skills:

• Familiarity with CMS appeals levels (e.g., Reopening, Redetermination)
• Working knowledge of ICD-10, CPT, HCPCS coding (preferred, not required)
• Proficiency with claims systems, Microsoft Office Suite (Word, Excel, Outlook), and electronic case management tools
• Strong organizational skills for tracking deadlines and managing documentation
• Excellent verbal and written communication skills
• Ability to interpret CMS regulations, MAC policies, and standard operating procedures

What We Offer

• Competitive hourly pay $18–$20 per hour
• Fully remote work flexibility
• Supportive, process-driven team culture
• Experience in a high-impact government healthcare contract environment

Segregation of Duties

Every employee is responsible to perform their duties and responsibilities in accordance with STAR's values, policies and procedures, including but not limited to, Segregation of Duties Principles, HIPAA Security and Privacy, and any other applicable laws, rules and regulations.

Statement of Other Duties

This document outlines the essential functions, requirements, and responsibilities of the position, and is not intended to be a complete list of all tasks and duties. Employees may be requested to perform job related tasks other than those specifically listed in this description and may be required to perform any task requested by the supervisor or by management.

Job Type: Full-time

Pay: $ $20.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Tuition reimbursement
• Vision insurance

Application Question(s):

• Do you have a High School diploma, Associates, or Bachelor's degree?
• Do you have experience with CMS appeals, such as reopenings and redeterminations?

Work Location: Remote