Appeal Analysts

Arkansas Blue Cross Blue Shield

1d • Onsite

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 in addition to the experience requirements listed below.
• 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.
• Sound Judgement
• HIPAA Confidentiality
• Legal Confidentiality
• Taking Initiative

Nice To Haves

• Working knowledge of insurance products, policies, procedures and/or claims processing

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level