Appeals Examiner #00064

Commonwealth of VA Careers; Richmond (VA); On-site; USD 85,000 - 100,000; Full time

Job summary

Commonwealth of VA Careers seeks an Appeals Examiner for the Dept of Human Resource Management in Richmond. The role conducts investigations of health benefits appeals, coordinates with independent review organizations, and oversees member complaints and audits to ensure policy compliance.

Qualifications emphasize health benefits knowledge, analytical ability, and strong communication. Applicants should be prepared for a background check and have excellent customer service skills.

Qualifications

• Comprehensive knowledge of health benefits policies and practices.
• Ability to interpret regulations governing appeals.
• Strong analytical skills to evaluate complex information.
• Proficiency in computer applications to prepare correspondence and reports.
• Excellent written and verbal communication skills.
• Strong organizational and time management abilities.
• Commitment to exceptional customer service.

Responsibilities

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

Job description

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

Job Duties

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.

Minimum Qualifications

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.

Additional Considerations

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.

Special Instructions

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.

Equal Opportunity Employer

Department of Human Resource Management

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

600 East Main Street, 17th Floor

Richmond, Virginia 23219

[phone]

Contact Information

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.