Appeals Examiner #00064

DHRM; Richmond (VA); Vor Ort; USD 85.000 - 100.000; Vollzeit

Zusammenfassung

Department of Human Resource Management seeks an Appeals Examiner to conduct comprehensive investigations of health benefits claims and administrative appeals, ensuring fairness and accuracy in outcomes.

The role involves evaluating clinical appeals, coordinating with independent review organizations, and guiding Benefits Administrators, employees, and retirees on policies and procedures. Strong analytical skills and proficiency with health benefits systems are required.

Qualifikationen

• Comprehensive knowledge of health benefits policies and program administration.
• Regulations and procedures governing appeals must be interpretable and applicable.
• Strong analytical skills to evaluate complex information and apply policies.
• Proficiency in computer applications to prepare correspondence and reports.

Aufgaben

• Conduct comprehensive investigations of claims and administrative appeals to ensure fairness and accuracy.
• Evaluate clinical appeals and coordinate reviews with contracted independent review organizations.
• Oversee intake and resolution of member complaints and system transaction audits.
• Provide guidance to state agency Benefits Administrators, employees, and retirees on relevant policies and procedures.

Kenntnisse

Analytical skills

Communication

Time management

Customer service

Regulatory interpretation

Ausbildung

Health benefits administration certification

Relevant higher education degree

Tools

Microsoft Office

Health benefits software

Jobbeschreibung

Title: Appeals Examiner #00064

State Role Title: Human Resource Analyst II

Hiring Range: $85,000.00 - $100,000.00

Pay Band: 5

Agency: Dept of Human Resource Mgt

Location: Main Street Center

Agency Website: www.dhrm.virginia.gov

Recruitment Type: General Public - G

The Department of Human Resource Management, Office of Health Benefits is seeking a qualified individual to fill the position of Appeals Examiner. This position will be responsible for conducting comprehensive investigations of claim and administrative appeals to ensure fairness, accuracy, and equitable outcomes for appellants. This role includes evaluating clinical appeals and coordinating reviews with contracted independent review organizations. In addition, the position will oversee the intake and resolution of member complaints and manages system transaction audits to ensure adherence to program policies. Also, this position will be responsible for providing guidance to state agency Benefits Administrators, employees, and retirees on relevant policies and procedures, and collaborates with OHB staff on projects and vendor compliance activities.

Comprehensive knowledge of health benefits policies and practices, including program administration and compliance requirements. Working knowledge of regulations and procedures governing appeals, with the ability to interpret and apply them effectively. Strong analytical skills to evaluate complex information and apply policies and regulations accurately. Proficiency in computer applications to prepare correspondence and reports. Excellent written and verbal communication skills, with the ability to convey information clearly and professionally. Strong organizational and time management abilities, including the capacity to set priorities, work independently, and meet objectives with minimal supervision. Commitment to exceptional customer service, ensuring responsiveness and professionalism in all interactions.

Experience with medical claims is preferred. Background in utilization review is highly desirable. Education, certification, or hands-on experience in health benefits administration and/or claims handling is preferred.

All applicants are subject to a background investigation. The investigation may include: fingerprint checks (State Police, FBI); local agency checks; employment verification; verification of education (relevant to employment); credit checks; and other checks requested by the hiring authority.

The Department of Human Resource Management is dedicated to recruiting, supporting, and maintaining a competent and diverse work force.

Equal Opportunity Employer

Department of Human Resource Management

600 East Main Street, 17th Floor

Richmond, Virginia 23219

[phone]

Name: Derek Mountford

Phone: [phone]

Email: [e-mail]

In support of the Commonwealth’s commitment to inclusion, we are encouraging individuals with disabilities to apply through the Commonwealth Alternative Hiring Process. To be considered for this opportunity, applicants will need to provide their AHP Letter (formerly COD) provided by the Department for Aging & Rehabilitative Services (DARS), or the Department for the Blind & Vision Impaired (DBVI). Service-Connected Veterans are encouraged to answer Veteran status questions and submit their disability documentation, if applicable, to DARS/DBVI to get their AHP Letter. Requesting an AHP Letter can be found at AHP Letter or by calling DARS at 800-552-5019.

Note: Applicants who received a Certificate of Disability from DARS or DBVI dated between April 1, 2022- February 29, 2024, can still use that COD as applicable documentation for the Alternative Hiring Process.

Advertised: 07 Oct 2026 Eastern Daylight Time

Applications close: 21 Oct 2026 Eastern Daylight Time