Grievances & Appeals Specialist I

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

Benefits offered by this job

Paid time off

Paid holidays

Insurance (medical/dental/vision/pharm

401(k) matching

Life insurance

Disability insurance (short/long term)

Education reimbursement

Employee assistance plan (EAP)

Adoption assistance

Paid family leave

Community service days

Self-care days

Job summary

Blue Cross of Idaho is seeking a Grievance & Appeals Specialist I to serve as the primary investigator for member appeals and grievances. You will analyze, research, and manage inventories, ensuring responses comply with regulatory requirements and plan policy.

The role requires 3 years of health industry experience and offers an annual incentive bonus based on performance. A robust benefits package is provided including PTO, insurance, 401(k) matching, and more.

Qualifications

• Minimum 3 years health industry or related experience.
• Strong verbal and written communication skills.
• Knowledge of ICD-10 and CPT coding.
• Experience with Individual and Group Contract language.
• Customer service or claims processing experience preferred.

Responsibilities

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

Skills

Verbal communication

Written communication

Medical terminology

ICD-10 / 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

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.

We offer a robust package of benefits including 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.

We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.

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.