Remote Appeals Analyst – Health Benefits & Compliance

Arkansas Blue Cross and Blue Shield; Little Rock (AR); Remote; USD 41,000 - 53,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an Appeals Analyst to review and respond to appeals and inquiries from members, providers, and regulatory bodies. The role requires independent judgment to determine legality and fairness of adverse benefit determinations, with adherence to applicable contracts and timelines.

The position emphasizes analytical thinking, strong knowledge of HIPAA/legal confidentiality, and experience in healthcare claims/appeals.

Qualifications

• Bachelor’s degree in related field or five years’ relevant experience in lieu of degree.
• Minimum three (3) years’ healthcare grievances, appeals, claims processing, claims research, customer service or related legal experience.
• Working knowledge of insurance products, policies, procedures and/or claims processing preferred.
• Experience using Microsoft Office i.e. Word and Excel.

Responsibilities

• Analyzes and responds to inquiries, complaints and/or concerns from members, providers, regulatory bodies and/or attorneys.
• Communicates medical coverage policy, processing guidelines and policy language with internal and external sources to facilitate, resolve, and respond to appeals within URAC/legal timeframe.
• Maintains administrative records of all case files, logging the appeal for each inquiry, and requesting relevant information from appropriate internal and external sources.
• Maintains a thorough knowledge of the benefit plans.
• Monitors the status of appeals.
• Performs other duties as assigned.
• Prepares written analysis that communicates facts and determinations for appeal responses within the timeframe.
• Recommends changes to the appeals process and contract language, as necessary, to minimize legal and regulatory liability.
• Utilizes current information from medical coding sources to ensure guidelines used in appeals are clear and concise.

Skills

Analytical decision making

Analytical problem solving

Business compliance

Claims management system

Continuous learning

Critical thinking

Cross-functional communications

CRM

Data analysis

Law

Management techniques

Microsoft Excel

Microsoft Office

Needs assessment

Sound judgment

Time management

Education

Bachelor’s degree in related field

Five years’ relevant experience in lieu of degree

Tools

CRM

Claims Management System

Microsoft Excel

Microsoft Office

Job description

Arkansas Blue Cross and Blue Shield is seeking an Appeals Analyst to review and respond to appeals and inquiries from members, providers, and regulatory bodies. The role requires independent judgment to determine legality and fairness of adverse benefit determinations, with adherence to applicable contracts and timelines.

The position emphasizes analytical thinking, strong knowledge of HIPAA/legal confidentiality, and experience in healthcare claims/appeals.