Appeals Analyst

Highmark Health; Northern (KY); Hybrid; USD 30,000 - 45,000; Full time

Job summary

Highmark Inc. seeks a Grievance/Appeals Specialist to review inquiries and determine eligibility under grievance and appeal definitions. You will document investigations and coordinate with internal and external parties as required to resolve cases.

Initiating case files, ensuring regulatory compliance, and summarizing results for all stakeholders are core duties; travel up to 25% may be required.

Qualifications

• Requires High School Diploma or GED.
• 3-5 years of relevant experience in grievance/appeals or related field.
• Knowledge of government regulations and claims processing workflows.

Responsibilities

• Review inquiries to determine if they meet the definition of appeal/grievance.
• Assemble and review all related documentation to create case files.
• Coordinate resolution results and relay findings to all involved parties.

Skills

Processing systems

Claims processing

Regulatory interpretation

Company products

Organizational skills

Verbal and written communication

Education

High School Diploma or GED

Job description

Company

Highmark Inc.

Job Summary

This job reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results.

Essential Responsibilities

• Review inquiries to determine if they meet definition of appeal/grievance.
• Request and review all related relevant documentation and assemble case file.
• Coordinate resolution results and relay investigative results with all involved parties.
• Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends.
• May support the Quality Assurance, Appeal and other quality committees.
• Other duties as assigned or requested.

Education

Required: High School Diploma or GED. Substitutions: None. Preferred: None.

Experience

Required: 3-5 years of relevant, progressive experience in the area of specialization. Exempted experience requirements effective August 2016. Preferred: Experience in Customer Service or a related field.

Licenses or Certifications

Required: None. Preferred: None.

Skills

• Knowledge of multiple processing systems and workflows
• Knowledge of claims processing methodologies
• Ability to interpret all government regulations
• Knowledge of company products
• Excellent organizational skills
• Strong verbal and written communication skills

Languages (Other than English)

None

Travel Requirement

0% - 25%

Physical, Mental Demands and Working Conditions

Position Type Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Occasionally Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Occasionally Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Pay Range

Pay Range Minimum: $21.96 Pay Range Maximum: $32.95 Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.