Appeals Specialist

Independence Blue Cross; Philadelphia (Philadelphia County); Sur place; USD 65 000 - 90 000; Plein temps

Résumé du poste

Independence Blue Cross seeks an Appeals Specialist to independently investigate, document, and process member and provider appeals across IBX lines of business in line with policy and regulatory requirements.

The role focuses on building audit-ready case files, validating appeal elements, and delivering timely determinations within delegated authority or through appropriate review channels.

Qualifications

• Minimum 3 years in healthcare operations.
• Experience in Utilization Management or Appeals and Grievances preferred.
• Working knowledge of plan products, benefits, and claims procedures.
• Ability to research and handle complex issues.
• Ability to collaborate with internal and external teams.
• Strong writing, editing, and proofreading skills.
• Excellent customer service, organizational, time management and communication skills.

Responsabilités

• Investigate and process appeals from receipt to closure while meeting regulatory and internal timelines.
• Validate accuracy of cases using member benefits and plan policies.
• Identify and reconcile discrepancies among appeal request, denial letter, and case data.
• Interpret benefits, EOC, SPD, and policy requirements to support appeals.
• Build complete case files documenting investigation and determinations.
• Prepare case notes and rationales explaining issues, research, evidence, and next steps.
• Submit external review packages within required timeframes and track outcomes.
• Communicate with members, providers, and partners; document communications in systems.
• Draft and validate correspondence with templates, addressees, appeal rights, timelines, and regulatory language.
• Initiate effectuation or adjustment requests and escalate delays impacting risk.
• Utilize IBX systems for case management, eligibility, and documentation.
• Manage daily inventory, prioritize aging cases, and elevate process barriers.
• Perform other duties as assigned.

Connaissances

Healthcare operations

Utilization Management

Appeals and Grievances

Plan benefits & coverage

Research & problem solving

Collaboration

Writing & editing

Customer service

Communication skills

Formation

Bachelor’s degree in healthcare administration / business / population health

Description du poste

The Appeals Specialist independently investigates, documents, and processes member and provider appeals across assigned IBX lines of business in accordance with IBX policies and procedures and applicable federal, state, contractual, and accreditation requirements. The Specialist validates the appeal request, classification, appellant authority, regulatory timeframe, member eligibility, benefits, claims, authorization history, denial rationale, and supporting documentation. The Appeal Specialist is responsible for building a complete and audit-ready case file, investigating the appellant argument inclusive of application of the correct benefit, policy, and procedural requirements. The Appeal Specialist renders administrative determinations within delegated authority or routes cases to the correct team for review and determination. The Appeal Specialist is responsible for creating accurate, compliant determination letters, initiating and monitoring required effectuations, and completing all case activities within established quality and timeliness standards.

Responsibilities

• Manage assigned appeals from case receipt through investigation, determination, notification, effectuation, and closure while meeting all regulatory and internal turnaround times.
• Validate accuracy of cases assigned using the appropriate policies and procedures applicable to the member’s benefit plan.
• Accurately identify the substance of the appeal and reconcile discrepancies among the appeal request, denial letter, claim, authorization, and case-system information. Escalate unclear or incorrectly routed cases before compliance is affected.
• Investigate the appellant argument by interpreting applicable member benefits, Evidence of Coverage, benefit booklets, Summary Plan Descriptions, claims history, Explanation of Benefits, authorization records, denial rationale, medical and claim-payment policies, CMS guidance, state requirements, and IBX operational reference materials.
• Build a complete case file to support the investigation and determination of the appeal in accordance with IBX documentation standards.
• Prepare clear case notes, claim summaries, case narratives, and decision rationales that accurately explain the issue, research performed, evidence reviewed, applicable benefit or policy provisions, determination, and required next steps.
• Prepare complete external review packages, submit them through the designated process within required timeframes, monitor for determinations, and document the outcome and follow-up actions.
• Communicate professionally with members, authorized representatives, providers, vendors, and internal business partners by telephone and in writing; conduct required outreach; and document each communication accurately in the appropriate system.
• Draft and validate acknowledgment, request-for-information, dismissal, and determination correspondence using the correct approved template, addressee, appeal rights, timeframe, rationale, benefit or policy reference, and required regulatory language.
• Initiate overturned case effectuation or claim adjustment requests, monitor completion, reconcile outstanding tasks and ticklers, and elevate delays that present member, financial, quality, or compliance risk.
• Use IBX appeal and supporting systems effectively, including the case management system, claims and eligibility platforms, authorization systems, document repositories, communication tools, policy libraries, and applicable vendor or external review portals.
• Manage daily inventory, prioritize expedited and aging cases, identify work at risk, meet productivity and quality expectations, and promptly elevate system, access, documentation, workload, or process barriers.
• Perform other duties as assigned.

Education

• A bachelor’s degree in healthcare administration, business, population health or related field.

Experience

• Minimum of 3 years working in healthcare operations required.
• Experience in Utilization Management or Appeals and Grievances preferred.

• Working knowledge of plan products, benefits, and claims procedures.
• Demonstrated ability to research and handle complex issues.
• Ability to collaborate with a variety of individuals both internally and externally.
• Writing, editing, and proofreading skills.
• Excellent customer service, organizational, time management and communication (verbal and written) skills.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Inclusion and Belonging

At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.

At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com . We’re revolutionizing health care, and our focus is on you!

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.