Appeal Analysts

Arkansas Blue Cross Blue Shield

2d•$41,100 - $53,400•Remote

About The Position

The Appeals Analyst reviews and responds to appeals and inquiries concerning adverse benefit determinations from members, providers, authorized representatives, insurance departments, and other regulatory bodies. The analyst works within federal and state legal timeframes and exercises independent judgment to assess whether each determination was legal, appropriate, impartial, and consistent with the applicable contract, without favoring the Company or the member. This role is remote for candidates working from home within Arkansas, Washington, Oregon, Utah, Idaho, North Dakota, or Minnesota. Preference is given to current employees and candidates residing in Arkansas, Utah, Idaho, or North Dakota. The position is identified as security level three and is responsible for protecting the confidentiality and integrity of records and information in accordance with the company Administrative Manual. The role must also follow the company’s segregation-of-duties guidelines.

Requirements

Bachelor’s degree in a related field; five years of relevant experience may be substituted for the degree in addition to the listed experience requirements.
At least three years of experience in healthcare grievances, appeals, claims processing, claims research, customer service, or related legal work.
Experience using Microsoft Office, including Word and Excel.
Sound judgment.
HIPAA confidentiality.
Legal confidentiality.
Ability to take initiative.

Nice To Haves

Working knowledge of insurance products, policies, procedures, and/or claims processing.
Preference is given to current employees and candidates residing in Arkansas, Utah, Idaho, or North Dakota.

Responsibilities

Analyze and respond to inquiries, complaints, and concerns from members, providers, regulatory bodies, and attorneys.
Communicate medical coverage policy, processing guidelines, and policy language to internal and external sources to facilitate and resolve appeals and respond within URAC and legal timeframes.
Maintain administrative records for case files, log each appeal, and request relevant information from appropriate internal and external sources.
Maintain thorough knowledge of benefit plans.
Monitor the status of appeals.
Prepare written analyses communicating facts and determinations for appeal responses within required timeframes.
Recommend changes to the appeals process and contract language, as necessary, to minimize legal and regulatory liability.
Use current information from medical coding sources to ensure appeal guidelines are clear and concise.
Perform other duties as assigned.
Protect the security, confidentiality, and integrity of records and information in accordance with the company Administrative Manual.
Adhere to segregation-of-duties guidelines in the Administrative Manual.