Claim Appeals Specialist (PACE)

The Phia Group allows employers who manage their own health benefit plans to submit complicated appeals regarding denied claims to The Phia Group, and we help ensure that payable claims get paid, while proper denials remain in place. To ensure these appeals and claims are handled properly, our Plan Appointed Claim Evaluator (“PACE”) team needs dedicated, organized, and passionate members.

As a PACE Claim Appeal Specialist, you will be responsible for maintaining status of client documents, review of clients summary plan documents, stop loss policies and employee handbooks, a, inventory and audit all incoming final internal appeals and external appeals

At The Phia Group, whose mission is to provide high quality yet affordable healthcare to American employees and their families, you can look forward to not only exceptional benefits for yourself but also being immersed in a company that was named one of USA Today’s Top Workplaces for 2026. Meanwhile, from a regional perspective, The Boston Globe, Courier Journal, and Louisville Business First annually recognize our unwavering commitment to upholding an internal culture of inclusivity, enjoyment, and empathy for our valued employees by listing The Phia Group in their respective lists for the Top Places to Work.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Maintain an inventory of client documents required and received
• Coordinate and review employer benefit plan documents and stop loss policy
• Communicate with clients regarding receipt and status of appeals
• Receive, audit and review all submitted final internal medical claims appeals and external medical claims appeals
• Prepare and summarize appeal content
• Assign appeal for review and response
• Create and coordinate timely status updates and responses to clients

Experience and Qualifications

• Minimum of 2 years of experience with employer benefit plan documents and reviewing of medical appeals
• Ability to utilize various case management software for the purpose of tracking appeals
• Excellent organizational skills and attention to details
• Excellent verbal and written communication skills
• Advanced knowledge of Microsoft Excel
• Ability to multi task with a high level of attention to detail
• Handles stressful situations and deadline pressures well
• Plans and carries out responsibilities with minimal direction

The Phia Group’s Commitment to Diversity

The Phia Group is committed to creating a diverse environment and we are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. The Phia Group is also committed to compliance with all fair employment practices regarding citizenship and immigration status.

Working Conditions / Physical Demands

Sitting at workstation for prolong periods of time. Extensive computer work. Workstation may be exposed to overhead fluorescent lighting and air conditioning. Fast paced work environment. Operates office equipment including personal computer, copiers, and fax machines.

This job description is not intended to be and should not be construed as an all-inclusive list of all the responsibilities, skills or working conditions associated with the position. While it is intended to accurately reflect the position activities and requirements, the company reserves the right to modify, add or remove duties and assign other duties as necessary.

External and internal applicants, as well as position incumbents who become disabled as defined under the Americans with Disabilities Act, must be able to perform the essential job functions (as listed here) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis.

Salary: $50,000 - $60,000