Sr Appeals Specialist

Independence Blue Cross; Philadelphia (Philadelphia County); On-site; USD 65,000 - 90,000; Full time

Job summary

Independence Blue Cross in Philadelphia is seeking a Sr Appeals Specialist to investigate appeals and grievances and prepare case files for clinical and administrative review. The role requires detailed policy understanding and coordination with internal teams and external vendors.

You will manage communications with members and providers, request records, and document investigations in the Appeals Management System, ensuring timeliness and quality in adherence with PID and DOBI guidelines.

Qualifications

• Knowledge of corporate medical policy and procedures.
• Understanding of HMO, PPO, and Medicare Advantage benefit structures.
• Proficiency with Microsoft Office, databases, and spreadsheet software.
• Excellent written and verbal communication skills.

Responsibilities

• Investigates clinical appeal requests and reviews applicable medical policies, guidelines, member handbook, benefits, claims, and medical records to identify the basis of the original decision.
• Makes outreach calls to Members, Providers, and/or Member representatives to acknowledge receipt of the appeal; requests medical records as needed.
• Prepares case documentation and packages for submission; documents the investigation in the Appeals Management System.
• Coordinates with IROs and reviews recommendations, ensuring timely follow-up and questions as needed.
• Creates appeal determination letters detailing rationale, policies, benefits, and future options; handles correspondence during the process.
• Initiates effectuation (adjustment) requests for overturned appeals and follows through to completion.
• Maintains regular contact with Medical Directors and external vendors; supports resolution timelines and quality standards.
• Supports CACs and Appeals Specialists with administrative tasks as needed.

Skills

Medical policy understanding

HMO/PPO knowledge

MS Office proficiency

Attention to detail

Communication skills

Education

High School diploma

Job description

The Sr Appeals Specialist investigates appeals and grievances in accordance with established policies and regulations. The Appeals Specialist is also responsible for the preparation of case files for both clinical and/or administrative review.

Responsibilities

• Investigates Clinical appeal requests reviews the applicable medical policy/guidelines, member handbook, benefits, claims, pre-authorizations, and the corresponding medical records to identify the basis of the original decision and establish an understanding of the appeal/dispute.
• Makes outreach calls to Members, Providers, and/or Member representative to acknowledge receipt of the appeal request.Requests medical records necessary for the appeal review.
• Prepares all case documentation (medical policy/guidelines, member handbook, Claims/Auth info, and medical records) and packages to submit for decision.Documents entire investigation in the Appeals Management System.
• Utilizes multiple Independent Review Organization (IRO) portals for submission of clinical appeals requiring matched-specialty review.Coordinates with IROs on time-sensitive cases, and availability of particular specialties.Reviews the IRO recommendation upon completion, and communicates back to the IRO with any questions or clarification needed.
• Creates appeal determination letters with a detailed description of the nature of the appeal, medical policy and benefits, the clinical rationale for the decision, and options moving forward.Additional correspondence may also be sent throughout the Appeals process.(automated letter process based off data entered in Appeals system)
• Initiates effectuation (adjustment) request for overturned appeals and follows through until completion.
• Regular contact with internal Medical Directors regarding appeal decisions, sign-offs, and input on complex clinical cases.
• Regular contact with external vendors including Future Scripts, Magellan, AIM, etc. to obtain additional information, records, policy, and correspondence from the initial determination.Coordinates effectuation process with vendor for overturned appeals.
• Responsible for complying with timeliness and quality standards regulated by State & Federal entities, including Pennsylvania Insurance Department (PID) and NJ Department of Banking and Insurance (DOBI).Additionally, adhere to policies and procedures set forth by the company, including contractual agreements with participating Providers.
• Identifies trending appeal issues and initiates discussions across the Team and/or to Management for review and analyzation.Provides input on possible process improvements.
• In addition to processing Clinical cases, Senior Appeals Specialists may handle administrative Complaints, regarding payment and benefits appeals; reviewing benefits, claims, and coverage to verify the initial denial was correct. Educates member/member advocate on the coverage and benefit information and administers the appeal determination.Creates and sends decision letter to the appellant.
• Provides support to Triage and Appeals Specialists with questions on complex cases that potentially require medical review.
• Provides Support to Clinical Appeals Coordinators (CACs) with administrative tasks during the appeal process.
• Performs other duties as assigned

Education

High School diploma: Undergraduate degree is preferred.

Experience

A minimum of 2 years working in the appeals department with demonstrated proficiency in attention to detail, and accuracy in appeal cases and motivation to learn more

Knowledge, Skills, Abilities

• Has a good understanding of corporate medical policy and procedures, possess a thorough understanding of HMO, PPO, and Medicare Advantage benefit structures, demonstrated proficiency in Micro Soft office products, database, spreadsheets software, precertification and claims systems.
• Excellent interpersonal skills to interact with internal and external customers.
• Self-motivated, highly organized, detail oriented, member advocate
• Possesses excellent written and communication skills.
• Ability to work through complex issues.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Inclusion and Belonging

At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group - together with its subsidiaries - is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.

At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com . We’re revolutionizing health care, and our focus is on you!

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.