Appeal Analysts

01 USAble Mutual Insurance Company; United States; Remote; USD 41,000 - 53,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an Appeals Analyst to review and respond to member, provider and regulatory inquiries about adverse benefit determinations. The role requires independent judgment to ensure legal and policy alignment while maintaining timely responses under URAC and state/federal rules.

The position supports in-home work within select states, emphasizing accurate documentation, data analysis, and cross-functional collaboration with claims and compliance teams to

Qualifications

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

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.]
• CoT_job_summary_short
• COMPANY NAME: Arkansas Blue Cross and Blue ShieldKEY POINTS: Appeals analysis, regulatory timeliness, independent judgment

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

Education

Bachelor’s degree in related field

Tools

Claims Management System

Job description

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.

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.

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

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.

Why? We Love our Employees

At Arkansas Blue Cross, we care about the health, wellness, and education of our employees. We offer many great incentives such as: Tuition reimbursement. Club Blue, a free, onsite gym to encourage exercise. Green Leaf Grill and Green Leaf Grill Express, onsite restaurants in Little Rock that promote healthy eating. Incentives for wellness education and exercise

We Love our Culture

The average tenure is 10 years with hundreds of employees having been here 15 years or longer. Our inclusive culture brings employees together to connect while celebrating our differences.

We Love our Community

Our employees often volunteer within their communities, at charity events, walks and runs, schools and nonprofits. When disasters strike, our employees help wherever they are needed. It’s just another way we show that Blue cares.