Appeals Analyst

Arkansas Blue Cross and Blue Shield

249d

About The Position

The Appeals Analyst reviews and responds to appeals and inquiries from members, providers, authorized representatives, insurance departments, and/or other regulatory bodies regarding adverse benefit determinations within the timeframes set forth in both federal and state law. This position must favor neither the Company nor the member and must exercise independent judgment in determining whether an adverse benefit determination was legal, appropriate, impartial and in accordance with the enterprise's obligation under the applicable contract.

Requirements

• Bachelor's degree in related field. In lieu of degree, five (5) years' relevant experience will be considered.
• 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.

Nice To Haves

• Excellent written and verbal communication; a writing assignment may be requested to demonstrate writing skills.
• Skills in Analytical Decision Making, Analytical Problem Solving, Business Compliance, Claims Management System, Continued Learning, Critical Thinking, Cross-Functional Communications, Customer Relationship Management (CRM), Data Analysis, Documenting/Recording Information (Inactive), Law, Management Techniques, Microsoft Excel, Microsoft Office, Needs Assessment, Sound Judgment, Time Management.

Responsibilities

• Analyzes and responds to inquiries, complaints and/or concerns from members, providers, regulatory bodies and/or attorneys; prepares written analysis of findings that communicate facts and determinations for appeal responses within the timeframe.
• Monitors the status of appeals.
• Effectively 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.
• Performs other duties as assigned.
• Recommends changes to the appeals process and contract language, as necessary, to minimize legal and regulatory liability.
• Utilizes current information from CMS/CPT/ICD 10 and other medical coding sources to ensure guidelines used in appeals are clear and concise.

Benefits

• Tuition reimbursement.
• Club Blue, a free, onsite gym to encourage exercise.
• Green Leaf Grill and Green Leaf Grill Express, onsite restaurants in Little Rock that promote healthy eating.
• Incentives for wellness education and exercise.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Bachelor's degree