Grievances & Appeals Specialist I

Blue Cross of Idaho; Carmel (IN); On-site; USD 33,000 - 46,000; Full time

Benefits offered by this job

Paid time off

Paid holidays

Insurance (medical/dental/vision)

401(k) matching

Life insurance

Disability coverage

Education reimbursement

Employee assistance program

Adoption assistance program

Paid family leave

Job summary

Blue Cross of Idaho is seeking a Grievance & Appeals Specialist I to analyze and manage member appeals and grievances, ensuring timely responses within regulatory requirements. The role involves classifying cases, preparing histories for committees, and presenting information to cross-functional teams.

Requirements include 3 years in health industry or related experience and skills in medical terminology, ICD10/CPT coding, and contract language.

Qualifications

• 3 years’ health industry or related experience.
• Classify and categorize cases accurately.
• Prepare case histories for committees and audits.
• Decide if additional information is needed for decisions.
• Apply business rules, policies and contract.

Responsibilities

• Investigate member appeals and grievances and manage inventories.
• Prepare appeal cases for independent specialty reviewer.
• Present appeal case information to a multi-department committee.
• Respond to member/provider requests within regulatory requirements.

Skills

Verbal communication

Medical terminology

ICD10/CPT coding

Contract language knowledge

Customer service / claims processing

Job description

Our Grievance & Appeals Specialist I act as the primary investigator for member appeals and grievances including analyzing, researching, and managing inventories. Responding to member/provider requests within regulatory requirements and plan policy.

We're looking for Grievance & Appeals Specialist I with:

Required Experience

• 3 years’ health industry or related experience

What a day of a Grievance & Appeals Specialist I would look like

• Ensure cases are accurately classified and categorized.
• Prepare comprehensive case histories for presentation and consideration at committee meetings and audits.
• Determines if additional information or documentation is needed to make appropriate decisions.
• Interpret and apply business rules, policies and contract.
• Prepare appeal cases to send to an independent specialty reviewer.
• Present appeal case information to a multi-department committee.

Additional skills that we are looking for

• Good verbal and written communication skills
• Medical terminology
• Familiar with ICD10 and CPT coding
• Experience with Individual and Group Contract language
• Customer Service or Claims processing experience preferred

Compensation

As of the date of this posting, a good faith estimate of the current pay range is $23.63 to $33.09. The position is eligible for an annual incentive bonus (variable depending on company and employee performance). The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.

Benefits

• paid time off
• paid holidays
• community service and self-care days
• medical/dental/vision/pharmacy insurance
• 401(k) matching and non-contributory plan
• life insurance
• short and long term disability
• education reimbursement
• employee assistance plan (EAP)
• adoption assistance program and paid family leave program

Legal & Accommodations

Reasonable accommodations To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

About Blue Cross of Idaho

Blue Cross of Idaho has taken our role as an Idaho-based health insurance company to heart since 1945. As a not-for-profit, we are driven to help connect Idahoans to quality and affordable healthcare while building strong networks and services. We aim to create a brighter future for all with the help of customer-centric professionals.

Your Health and Wellness Matters

At Blue Cross of Idaho, we care about the health and well-being of our employees. Our benefits aim to help make your life easier, healthier and more balanced.

Your Career Development Matters

We believe in employee growth, which is why we offer training, tools and numerous resources to assist with professional development.

Your Community Matters

Our employees care deeply about Idaho. We work together to positively impact communities throughout Idaho, and contribute our time through volunteering.

Blue Cross of Idaho will extend reasonable accommodations to qualified individuals with disabilities who are otherwise not able to fully use electronic and online job application systems.

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