Remote Appeals Analyst – Healthcare Compliance & Research

01 USAble Mutual Insurance Company; United States; 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 member, provider and regulatory inquiries about adverse benefit determinations. The role requires independent judgment to ensure legal and policy alignment while maintaining timely responses under URAC and state/federal rules.

The position supports in-home work within select states, emphasizing accurate documentation, data analysis, and cross-functional collaboration with claims and compliance teams to

Qualifications

• Bachelor’s degree in related field; in lieu of degree, five years’ experience considered.
• Minimum three years healthcare grievances, appeals, claims processing or related legal experience.
• Working knowledge of insurance products, policies, procedures and/or claims processing.
• Experience using Microsoft Office (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.]
• CoT_job_summary_short
• COMPANY NAME: Arkansas Blue Cross and Blue ShieldKEY POINTS: Appeals analysis, regulatory timeliness, independent judgment

Skills

Analytical Decision Making

Analytical Problem Solving

Business Compliance

Claims Management System

Continuous Learning

Critical Thinking

Cross-Functional Communications

Customer Relationship Management (CRM)

Data Analysis

Law

Management Techniques

Microsoft Excel

Microsoft Office

Needs Assessment

Sound Judgment

Time Management

Education

Bachelor’s degree in related field

Tools

Claims Management System

Job description

Arkansas Blue Cross and Blue Shield is seeking an Appeals Analyst to review and respond to member, provider and regulatory inquiries about adverse benefit determinations. The role requires independent judgment to ensure legal and policy alignment while maintaining timely responses under URAC and state/federal rules.

The position supports in-home work within select states, emphasizing accurate documentation, data analysis, and cross-functional collaboration with claims and compliance teams to