Appeal Analysts

Arkansas Blue Cross and Blue Shield; Little Rock (AR); A distancia; USD 41.000 - 53.000; Jornada completa

Descripción de la vacante

Arkansas Blue Cross and Blue Shield is seeking an Appeals Analyst to review and respond to appeals and inquiries from members, providers, and regulatory bodies. The role requires independent judgment to determine legality and fairness of adverse benefit determinations, with adherence to applicable contracts and timelines.

The position emphasizes analytical thinking, strong knowledge of HIPAA/legal confidentiality, and experience in healthcare claims/appeals.

Formación

• Bachelor’s degree in related field or five years’ relevant experience in lieu of degree.
• Minimum three (3) years’ healthcare grievances, appeals, claims processing, claims research, customer service or related legal experience.
• Working knowledge of insurance products, policies, procedures and/or claims processing preferred.
• Experience using Microsoft Office i.e. Word and Excel.

Responsabilidades

• Analyzes and responds to inquiries, complaints and/or concerns from members, providers, regulatory bodies and/or attorneys.
• Communicates medical coverage policy, processing guidelines and policy language with internal and external sources to facilitate, resolve, and respond to appeals within URAC/legal timeframe.
• Maintains administrative records of all case files, logging the appeal for each inquiry, and requesting relevant information from appropriate internal and external sources.
• Maintains a thorough knowledge of the benefit plans.
• Monitors the status of appeals.
• Performs other duties as assigned.
• Prepares written analysis that communicates facts and determinations for appeal responses within the timeframe.
• Recommends changes to the appeals process and contract language, as necessary, to minimize legal and regulatory liability.
• Utilizes current information from medical coding sources to ensure guidelines used in appeals are clear and concise.

Conocimientos

Analytical decision making

Analytical problem solving

Business compliance

Claims management system

Continuous learning

Critical thinking

Cross-functional communications

CRM

Data analysis

Law

Management techniques

Microsoft Excel

Microsoft Office

Needs assessment

Sound judgment

Time management

Educación

Bachelor’s degree in related field

Five years’ relevant experience in lieu of degree

Herramientas

CRM

Claims Management System

Microsoft Excel

Microsoft Office

Descripción del empleo

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here.

Job Summary

The Appeals Analyst reviews and responds to appeals and inquiries from members, providers, authorized representatives, insurance departments, and/or other regulatory bodies regarding adverse benefit determinations within the timeframes set forth in both federal and state law. This position must favor neither the Company nor the member and must exercise independent judgment in determining whether an adverse benefit determination was legal, appropriate, impartial and in accordance with the enterprise’s obligation under the applicable contract.

Requirements

EDUCATION

• Bachelor’s degree in related field. In lieu of degree, five (5) years' relevant experience will be considered in addition to the experience requirements listed below.

Experience & Knowledge

• Minimum three (3) years' healthcare grievances, appeals, claims processing, claims research, customer service or related legal experience. Working knowledge of insurance products, policies, procedures and/or claims processing preferred. Experience using Microsoft Office i.e. Word and Excel.

Essential Abilities

• Sound Judgement HIPAA Confidentiality Legal Confidentiality Taking Initiative

LOCATION

Work from home within Arkansas, Washington, Oregon, Utah, Idaho, North Dakota, or Minnesota. Preference will be given to current employees and candidates who reside in Arkansas, Utah, Idaho, and North Dakota.

Skills

• Analytical Decision Making
• Analytical Problem Solving
• Business Compliance
• Claims Management System
• Continuous Learning
• Critical Thinking
• Cross-Functional Communications
• Customer Relationship Management (CRM)
• Data Analysis
• Law
• Management Techniques
• Microsoft Excel
• Microsoft Office
• Needs Assessment
• Sound Judgment
• Time Management

Responsibilities

• Analyzes and responds to inquiries, complaints and/or concerns from members, providers, regulatory bodies and/or attorneys.
• Communicates medical coverage policy, processing guidelines and policy language with internal and external sources to facilitate, resolve, and respond to appeals within URAC/legal timeframe.
• Maintains administrative records of all case files, logging the appeal for each inquiry, and requesting relevant information from appropriate internal and external sources.
• Maintains a thorough knowledge of the benefit plans.
• Monitors the status of appeals.
• Performs other duties as assigned.
• Prepares written analysis that communicates facts and determinations for appeal responses within the timeframe.
• Recommends changes to the appeals process and contract language, as necessary, to minimize legal and regulatory liability.
• Utilizes current information from medical coding sources to ensure guidelines used in appeals are clear and concise.

Certifications

Hiring Range

$41,100.00 - $53,400.00

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.