Appeal & Inquiry Advocate

Wellmark, Inc.•Des Moines, IA

1d•Hybrid

About The Position

Are you someone who enjoys solving complex problems and digging into the details until you find the right answer? Do you take pride in turning that research into clear, polished written communication that others can easily understand? If you thrive in an environment where every case is a puzzle and every outcome matters, the Appeal & Inquiry Advocate role may be a great fit for you. Bring your curiosity, critical thinking, and knack for writing – we’ll bring the opportunity to make a real impact. In this role you will review, research and respond to formal written pre- and post-service appeals, providing accurate, timely, customized and professional responses to customers. Deliver value-based service by leveraging broad knowledge of Wellmark's ecosystem to ensure thorough research and accurate outcomes, enhancing the customer experience. Educate and advocate for Wellmark customers based on their appeal situation, helping them understand products and services and instilling confidence.

Requirements

High School Diploma or GED.
3+ years of insurance or related industry experience in appeals or research-focused roles, applying strong analytical skills to investigate complex information and provide clear, well supported guidance and responses to customers.
Demonstrated strong written and verbal communication skills, with the foundational requirement to independently create explanatory and educational content from scratch, clearly and concisely conveying complex information, key findings, and outcomes.
Strong independent organizational, decision-making, and time management skills, with keen attention to detail and a proven ability to prioritize competing demands, meet deadlines, and confidently assess urgency.
Ability to identify and approach complex problems from different angles and apply technical knowledge to policies/procedures.
Ability to identify issues or inconsistencies; obtains relevant information, relates and compares data from different sources and identifies alternative solutions.
Demonstrated interpersonal skills, with the ability to build and maintain collaborative relationships.
Proven experience in Microsoft Office Suite, with experience navigating through various internal systems.

Nice To Haves

Health Insurance experience, including knowledge of benefits, eligibility, claims, pricing, payment integrity, medical coding, and ability to read and understand insurance regulations is preferred.
Prior paralegal experience preferred.

Responsibilities

Thoroughly investigate, analyze, and resolve complex pre- and post-service appeals across all company areas, including Claims, Membership & Enrollment, Customer Service, Marketing, Network Economics, Network and Provider Relations, Credentialing, Sales Account Management, Benefits Implementation, Government Programs, Pharmacy, and Clinical and Care Management. Assess inquiries, research relevant information in various systems, compare original processing to benefit certificates, contracts, medical records, or other documents, and consult stakeholders or legal as needed.
Respond in writing to appeals or complaints within regulatory timeframes by effectively assessing priorities and meeting all deadlines.
Prepare appeal files for medical review by clinicians, ensuring compliance with Medical Policies and Utilization Management standards, including independent review and assessment of secondary medical records.
Collaboration with partner Blue Plans to resolve inter-plan processing issues related to appeals by independently utilizing BlueSquared communication tool.
Make outbound calls to providers to assist with appeal or complaint resolution when applicable.
Thoroughly document all appeals and complaints as set by audit and regulatory standards.
Clearly communicate claim remediation needs to an adjuster, when applicable, by providing direction to appropriately result in the needed appeal outcome.
Track and trend potential compliance issues as noted through ongoing appeal review, following Wellmark's notification protocol.
Conduct root cause analysis and use data-driven decisions to recommend process improvements across the organization.
Deliver meaningful presentations to present findings and/or detailed written explanation to stakeholders to support appeal decision outcomes, as needed and/or requested.
Support applications and systems across multiple business areas to understand usage and ensure data integrity. Analyze, define, and validate business requirements for system modifications, enhancements, upgrades etc.
Consistently communicate and collaborate with senior team members on ongoing initiatives and changes (integrations, file transfers, system reports, etc.), ensuring expected outcomes.
Meet performance standards and comply with other job requirements as established and communicated by leadership.
Other duties as assigned.