Reimbursement Appeals Specialist - Hybrid

Position Summary

The Reimbursement Appeals Specialist is responsible for processing and managing prior authorization and claim denial appeals for the Walkasins System across third-party payers. The Appeals Specialist will gather supporting documentation, prepare and submit appeal packages, and track cases through resolution. This role requires strong attention to detail, comfort with payer communication, and the ability to manage multiple active cases simultaneously under strict deadlines. 

This role is hybrid (onsite - T, W & TH) and located in our Eden Prairie Corporate office.

Job Responsibilities

Responsibilities include, but are not limited to, the following:

•        Review denial communications including EOBs and denial letters for prior authorization denials and claim denials to identify appeal opportunities and next steps

•        Gather and compile supporting documentation including clinical records and physician letters of medical necessity required for appeal submissions

•        Prepare appeal letters and packages ensuring submissions are accurate, complete, and compliant with payer requirements

•        Submit appeals through the appropriate channel for each payer including payer portals, fax, and mail, following payer-specific submission requirements

•        Contact payers by phone to confirm appeal processes, submission requirements, and case status

•        Track appeal deadlines across all active cases and ensure timely submission within payer-defined timeframes

•        Perform proactive follow up with payers on pending appeals to drive timely resolution

•        Manage cases through multiple levels of appeal including reconsideration, External Medical Review, and phone hearings as needed

•        Communicate appeal status and expected timelines to the sales team and patients

•        Contact patients as needed to provide updates on appeal status and next steps

•        Maintain accurate and detailed records of all appeal activity, submissions, and outcomes in internal systems

•        Surface denial trends and case patterns to senior team members

•        Handle patient information with discretion and maintain HIPAA compliance

•        Understand and comply with third-party payer and Medicare rules and regulations

•        Other duties as assigned

Required Qualifications

•        Minimum 3-5 years of third-party authorization experience with direct interaction with payers

•        Prior experience with payer appeals processes, including preparing and submitting appeal packages for prior authorization and claim denials

•        Strong written communication skills and ability to prepare clear, well-organized written correspondence

•        Exceptional attention to detail - appeal submissions must be accurate and complete; errors can result in lost appeal rights or delayed reimbursement

•        Comfortable with high-volume payer and patient phone contact as a routine part of the role

•        Working knowledge of payer coverage determination criteria, medical necessity standards, and appeals processes

•        Strong organizational skills and ability to manage multiple active cases simultaneously under strict filing deadlines

•        Extensive knowledge of medical insurance plan benefit structures

•        Ability to work independently as well as in a team environment

•        Proficiency in Microsoft Office software suite

•        Flexible and able to adapt to process and system changes in a growing environment

Preferred Qualifications

•        Associate's degree or higher preferred

•        3+ years specific industry experience, preferably in health insurance and/or durable medical equipment

•        Experience with medical device, DME, or DMEPOS reimbursement

•        Familiarity with prosthetic device benefit categories and HCPCS coding

Physical Requirements:

•        The physical demands described within the Responsibilities section of this job description are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

•        The employee is also required to use a computer and communicate with others.