appeals specialist resume example with 6 years of experience

Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000,
Websites, Portfolios, Profiles
Professional Summary

Experienced Appeals Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Familiar with reviewing regulations and policies related to the Affordable Care Act.

  • Insurance industry experience
  • Reporting skills
  • Collaborative relationships
  • Documentation abilities
  • Excellent administrative abilities
  • Affordable Care Act policy expertise
  • Policy compliance understanding
  • Microsoft Word
  • Negotiation and mediation skills
  • Multitasking and Prioritization
  • Verbal and Written Communication
  • Upbeat and Positive Personality
Work History
06/2021 to Current Appeals Specialist Bluecross Blueshield Of South Carolina | Richland County, SC,
  • Reduced appeal resolution times by 59% through process improvement
  • Reduced Appeal Hearing requests by 100% in 2021
  • Manage the receipt, investigation and resolution of all appeals and Idaho Department of Insurance Complaints
  • Generate, analyze and present weekly, monthly and quarterly data to YHI upper management, CEO, Board of Directors and CMS
  • Review and analyze policy changes related to the Affordable Care Act
  • Create and maintain Policy Steering Team agendas
  • Provide high level summary and explanation of policy changes to all staff members
  • Acted as policy and appeals subject matter expert, answering internal and external questions and inquiries
  • Create, review and implement procedures related to appeals and policy
05/2019 to 06/2021 Appeals Coordinator Centene Corporation | Russell, AR,
  • Implemented electronic appeal submission method reducing the number of printed pages by 33.33% for each appeal
  • Reduce the appeal intake time by 24.54%
  • Manage the receipt, investigation and resolution of standard complaint and appeal issues in a timely and highly effective manner
  • Generate and present reports related to daily, weekly, monthly and quarterly appeal trends
  • Collaborate with training team members to ensure policy related questions were answered and addressed accurately in trainings
  • Compile and prepare documentation for presentation to consumers, board members and YHI leadership in relation to Appeal Hearings
  • Created, composed and maintained appeal response templates.
  • Developed appeals functions, policies and procedures, and documentation.
  • Acted as Policy and Appeal subject matter expert, answering internal and external questions and inquiries.

03/2018 to 05/2019 Business Analyst Altus Group Limited | Tampa, FL,
  • Reviewed, analyzed and evaluated business system and user needs while utilizing data in support of operational requirements
  • Identified and documented high level business case requirements including project scope
  • Wrote and executed test cases for system releases
  • Investigated and tracked system bugs and defects
  • Transformed complex, ambiguous and abstract requirements into smaller components and features
  • Completed weekly, monthly and quarterly CMS reporting in relation to system errors and other data pertaining to enrollment metrics
  • Documented and created business process flows as requested in cross departmental meetings
  • Periodic data analysis pertaining to exchange enrollment metrics including data as it related to Medicaid expansion
  • Evaluated and submitted system enhancement requests as they related to policy needs
  • Reviewed and restructured external facing notices to ensure policy compliance and verbiage accuracy
09/2016 to 03/2018 Appeals Coordinator Compsych | Chicago, IL,
  • Worked closely with members of the Idaho Department of Insurance, Idaho Department of Health and Welfare, Board members, insurance carriers and policy analyst to resolve grievances
  • Met federal mandated deadlines for appeals and CMS reports
  • Researched and analyzed complex appeal cases and made decisions based on policy and the Code of Federal Regulations
  • Tracked and educated on appeal trends within the company
  • Streamlined the appeal intake and tracking process
  • Cross trained seasonal staff to intake and process appeals
  • Managed and provided feedback on appeals processed by YHI staff
Expected in 2013 to to Bachelor of Arts | Anthropology, Psychology Boise State University, Boise, ID GPA:

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Resume Overview

School Attended

  • Boise State University

Job Titles Held:

  • Appeals Specialist
  • Appeals Coordinator
  • Business Analyst
  • Appeals Coordinator


  • Bachelor of Arts

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