Health Plan Appeals Specialist

Independence Blue Cross; Philadelphia (Philadelphia County); On-site; USD 60,000 - 85,000; Full time

Job summary

Independence Blue Cross seeks an Appeals Specialist to investigate and resolve member and provider appeals and grievances. You will research cases, evaluate benefit plans, claims history, and provider records, then prepare complete files for review and communicate outcomes to stakeholders.

The role requires meticulous case documentation, adherence to policies and timelines, and strong collaboration with internal teams and external partners.

Qualifications

• Associate degree or equivalent combination of education and relevant experience in customer service, health insurance operations, claims, appeals, grievances, case management, or a related field.
• Experience in appeals, grievances, claims, customer service, case intake, case triage, or a related health insurance operations function is preferred.
• Working knowledge of health plan products, benefit structures, eligibility, authorizations, provider networks, claims processing, and explanation‑of‑benefits information is preferred.
• Ability to interpret policies, procedures, benefit documents, correspondence, and case records and to apply requirements consistently to individual cases.
• Demonstrated research, analytical, and problem‑solving skills, including the ability to reconcile information from multiple systems and identify gaps, inconsistencies, and appropriate next steps.
• Strong written communication, editing, proofreading, and verbal communication skills, with the ability to explain complex information clearly and professionally.
• Excellent customer service, organization, time‑management, follow‑through, and interpersonal skills.
• Ability to handle confidential information appropriately and comply with applicable privacy and information‑security requirements.
• Proficiency with Microsoft Word, Excel, Outlook, and web‑based case‑management or workflow systems is preferred, along with the ability to learn new applications and processes quickly.

Responsibilities

• Conduct comprehensive research for assigned appeals and grievances, including review of enrollment and eligibility, provider participation status, benefit plan provisions, authorization records, claim history, clinical or administrative documentation, prior correspondence, and the circumstances surrounding the denial of services or rejection of claims.
• Assess each submission to confirm that it meets applicable appeal or grievance criteria, identify the appropriate case type, category, subcategory, level of review, and root cause, and document the classification accurately in designated systems.
• Validate case jurisdiction, timeliness, standing, authorization to represent, and required supporting documentation; identify missing or conflicting information and initiate appropriate outreach or escalation.
• Apply relevant organizational policies, benefit language, contracts, regulatory requirements, and departmental procedures when researching and processing cases, escalating complex, urgent, or high‑risk matters to the appropriate resource.
• Prepare accurate, organized, and complete case files for clinical and/or administrative review, including a concise case summary, relevant evidence, prior determinations, correspondence, and any required review materials.
• Communicate with members, authorized representatives, providers, vendors, and other stakeholders verbally and in writing in accordance with departmental standards and required timeframes.
• Draft clear, professional, and accurate acknowledgment, information‑request, status, and determination correspondence using approved templates and language, with appropriate review when required.
• Document all case activity, research findings, decisions, communications, follow‑up actions, and supporting rationale completely and accurately in the applicable systems.
• Coordinate with internal departments and external resources, such as claims, customer service, utilization management, clinical reviewers, provider services, compliance, legal, and delegated vendors, to obtain information and support timely case resolution.
• Maintain case records and supporting documents in accordance with departmental filing, naming, retention, privacy, and quality‑assurance requirements.
• Organize and submit case documentation for external or independent review in accordance with applicable regulatory, contractual, and departmental guidelines.
• Manage an assigned caseload by prioritizing work according to due dates, case urgency, regulatory requirements, and departmental service‑level expectations; monitor open tasks and complete follow‑up activities promptly.
• Meet established expectations for timeliness, accuracy, productivity, quality, and customer service, and promptly report barriers that may affect compliance or case completion.
• Participate in training, calibration sessions, quality reviews, audits, and process‑improvement activities; incorporate feedback and remain current on policy, system, product, and regulatory changes.
• Protect confidential and sensitive information and follow all applicable privacy, security, and records‑management requirements.
• Perform other duties and support special projects as assigned.

Skills

Attention to detail

Time management

Communication

Analytical skills

Learning new applications

Education

Associate degree

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Independence Blue Cross seeks an Appeals Specialist to investigate and resolve member and provider appeals and grievances. You will research cases, evaluate benefit plans, claims history, and provider records, then prepare complete files for review and communicate outcomes to stakeholders.

The role requires meticulous case documentation, adherence to policies and timelines, and strong collaboration with internal teams and external partners.