Appeals Analyst

Highmark; United States; On-site; USD 30,000 - 45,000; Full time

Job summary

Highmark Inc. is seeking a case reviewer to determine if inquiries meet grievance/appeal definitions, assemble case files, and coordinate resolutions with internal and external parties. The role ensures regulatory compliance and clear documentation of investigation results.

The position involves supporting QA and appeal processes, participating in trend analysis, and collaborating with cross-functional teams to improve grievance handling. Strong communication is essential.

Qualifications

• This job requires 3-5 years of relevant, progressive experience in the area of specialization.

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.

Skills

Knowledge of multiple processing

Claims processing methodologies

Interpret government regulations

Knowledge of company products

Excellent organizational skills

Strong verbal and writtencommunication

Education

High School Diploma or GED

Job description

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.

Company

Highmark Inc.

Job Description

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

• 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.

Experience - Preferred

• Experience in Customer Service or a related field

Licenses or Certifications - Required

• 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

Pay Range Minimum

$21.96

Pay Range Maximum

$32.95

Disclaimer

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.

Compliance Requirement

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

HIPAA Compliance

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

EEO Statement

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.

Accessibility

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Accommodation Requests

For accommodation requests, please contact HR Services Online at [e-mail]

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