Appeals Analyst-Kansas City area
About The Position
The Appeals Analyst processes complaints, grievances, and appeals from members and providers, along with other assigned projects. The role gathers and reviews information from Blue KC systems and personnel, providers, members, and external medical review organizations to determine appropriate resolutions. Work must be documented according to department Standard Operating Procedures so that another analyst could reasonably reach the same conclusion. The analyst develops timely and accurate responses that comply with applicable federal and state requirements, Blue Cross and Blue Shield Association requirements, accreditation requirements, and department procedures. The role also communicates required follow-up actions to operational areas and tracks those actions to ensure they are completed accurately and on time. Working from home may be permitted with management approval, generally based on business needs and employee performance.
Requirements
- Bachelor’s degree in business, finance, accounting, law, health care administration, or another relevant academic discipline, or four years of relevant experience in the health insurance industry.
- 1–3 years of experience at a health insurer researching and responding to customer claim or benefit issues, or in a related role providing working knowledge of health plan benefits, major business systems, and operational processes.
- Ability to communicate effectively with members, providers, Blue KC employees, and senior management about complaints, grievances, or appeals.
- Ability to compose professional business correspondence, including communication of complex processes and decisions.
- Working knowledge of member health benefit certificates.
- Thorough knowledge of major BCBSKC lines of business, business systems, and operational processes.
- Working knowledge of BCBSKC medical policies.
- Working knowledge of federal and state, Blue Cross and Blue Shield Association, and accrediting body requirements related to complaints, grievances, and appeals.
- Thorough knowledge of BCBSKC member health benefits certificates.
Nice To Haves
- 2–4 years of experience processing complaints, grievances, and appeals at a health insurer.
Responsibilities
- Gather and review information needed to resolve complaints, first- and/or second-level grievances, and appeals.
- Document work according to department Standard Operating Procedures so another Appeals Analyst could reasonably reach the same conclusion.
- Prepare timely, accurate responses to complaints, grievances, and appeals in compliance with applicable requirements and procedures.
- Communicate follow-up actions to operational areas, such as claim adjustments for overturned decisions.
- Follow up to ensure operational actions are completed accurately and on time.
- Complete other projects as assigned.
Benefits
- Comprehensive medical, dental, and vision benefits.
- 401(k) plan with employee and employer contributions.
- Annual incentive bonus plan based on company achievement of goals.
- Paid holidays, paid time off, and volunteer time off.
- Professional development courses and mentorship opportunities.
- Tuition reimbursement program.
- Paid parental leave and adoption leave with adoption financial assistance.
- Employee discount program.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
