Appeals Specialist - St. Luke's Health Plan

St. Luke's Health System•Boise, ID

About The Position

At St. Luke’s Health Plan, we’re on a mission to connect people with affordable, hassle-free health care. We are the only health plan in Idaho putting doctors and insurance on the same team to deliver a more efficient and quality health care experience with less stress. Join us in this bold ambitious journey! The Appeals Specialist for St. Lukes Health Plan is responsible for intake, investigation and resolution of appeals, complaints, and grievance scenarios for all products, which may contain multiple issue and may require coordination of responses from multiple business units. This role focuses on determining responses for commercial group and individual plans (including on and off exchange), self-funded plans (including ERISA and non-ERISA), and Medicare Advantage plans. The Appeals Specialist ensures timely, accurate, and fair outcomes while supporting member satisfaction and maintaining compliance.

Requirements

Bachelors degree or experience in lieu of a degree
2 years relevant experience

Responsibilities

Manages the investigation and resolution of general appeals and grievances in compliance with regulatory requirements and company policies.
Prepares and facilitates Member appeals, complaints, and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully.
Conducts thorough investigations to complete comprehensive reviews, often collaborating with internal departments to gather necessary information. When necessary, triage incomplete components of appeals, complaints, and grievance to appropriate subject matter expert within another business unit for resolutions response content to be included in final resolution response.
Drafts clear, accurate, and timely correspondence to members and providers. Ensures timely, customer focused response to appeals, complaints and grievances including the notice of determination. Identifies and reports trends and emerging issues and provides recommend solutions.
Maintains precise documentation of all activities, decisions, and correspondence in the system.
Ensures appropriate routing of appeals and grievances during all steps of the process.
Maintains knowledge of and adheres to all applicable laws and regulations for appeals and grievances set forth by Federal and State regulatory bodies. Communicates updates to laws and regulations to appropriate stakeholders.
Maintains a complete and accurate database via departmental software for reporting and tracking and trending purposes.
Serves as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise. Recommends improvements and modifications to departmental operating procedures to maximize operating efficiency.