Sr Appeals Specialist

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

Job summary

Independence Blue Cross, LLC seeks a Senior Appeals Specialist to investigate clinical appeals and grievances, review policies, and prepare case files for reviews. You will coordinate with IROs, draft detailed appeal determinations, and ensure timely resolutions in accordance with regulatory standards.

The role involves outreach to members and providers, data documentation, and collaboration with Medical Directors and external vendors to support complex cases. An Equal Opportunity Employer.

Qualifications

• High School diploma is required; undergraduate degree preferred.
• Minimum of 2 years in the appeals department with detail-oriented accuracy.
• Thorough understanding of HMO, PPO, and Medicare Advantage benefit structures.
• Proficient in Microsoft Office, databases, and claims systems.

Responsibilities

• Investigates clinical appeal requests by reviewing medical policy, member handbook, benefits, and records to identify the basis of the original decision.
• Makes outreach calls to Members, Providers, or representatives to acknowledge receipt and obtain necessary records.
• Prepares case documentation and packages for decision, documenting the investigation in the Appeals Management System.
• Coordinates with IRO portals for clinical appeals and reviews, and communicates questions or clarifications.
• Creates appeal determination letters describing the appeal, policy, benefits, rationale, and options.
• Initiates and follows through on effectuation requests for overturned appeals.
• Maintains regular contact with Medical Directors and external vendors to obtain information and support the process.
• Ensures timeliness and quality standards per State & Federal entities and company policies.
• May handle administrative complaints, educate on coverage, and issue final decision letters.
• Provides support to Triage and CACs with complex cases and performs quality checks.

Skills

Appeals processing

Regulatory knowledge

Attention to detail

Communication

Microsoft Office

Education

High School diploma

Tools

None

Job description

Job Summary

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, preauthorizations, 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 matchedspecialty review. Coordinates with IROs on timesensitive 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, signoffs, 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 quality checks/reviews.
• 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.
• Selfmotivated, 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.