Gov't Programs Appeals & Grievances Specialist

Capital Blue Cross•Harrisburg, PA

About The Position

Position Description Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market-driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” The Specialist is responsible identifying, reviewing and analyzing policy and procedure issues and providing recommendations for solutions. Ensures compliance with organizational, CMS and other regulatory requirements. Appeals cover topics pertaining to enrollment, billing, benefits, and claims for various types of coverage offered under our PPO, HMO, Secure Rx and Medicare Supplemental Programs. Knowledge of Medicare, CMS regulations, medical, prescription, dental, vision, chiropractic, disease management, benefits management, and other programs administered/supported by Capital BlueCross and Avalon.

Requirements

Demonstrates ability to communicate effectively and professionally both verbally and in writing with all levels of internal/external personnel in order to respond to customer inquiries ranging from routine to complex and involving sensitive subject matter
Demonstrates ability to understand and interpret detailed policies and procedures and to be able to apply them to various situations. This includes thorough understanding of CBC’s responsibility to maintain privacy of Protected Health Information as required by the Health Insurance Portability and Accountability Act.
Demonstrates ability to work independently, be flexible and react appropriately to changing job assignments and work environments.
Demonstrates analytical, organizational, and problem solving skills in order to accurately and efficiently identify, analyze and respond to customer/provider appeals, as well as identify and analyze trends and discrepancies.
Familiar with, or ability to, operate a PC and associated software; Microsoft Word, Excel, etc., phone equipment, calculator, fax, copier, and other department required hardware.
Demonstrated competency in Windows (Outlook, Word, Internet Explorer, Excel and PowerPoint)
Above average reading, writing and arithmetic skills required (reading/math comprehension)
Knowledge of benefit programs administered and/or supported by Capital BlueCross. Includes Medicare Advantage, Medicare Part D and Medicare Supplemental Programs, Dental, Vision, Chiropractic, Prescription Drug, Benefits Management, and Disease Management.
Knowledge of the PBM and Facets health plan administration processing systems as well as online files for determining enrollment, billing, and benefits.
Knowledge of benefits administration policies, customer billing processes, claims processing and general procedures.
Knowledge of CMS guidance, in particular, Chapter 6 (formulary), Chapter 13 and Chapter 18 appeals regulations and processes.
Knowledge of Medicare compliance obligations
Knowledge of Medicare marketing and sales regulations and obligations
Knowledge of NCQA, BCBSA MTM, and HIPAA quality and timeliness guidelines and standards to ensure they are consistently met or exceeded.
Knowledge of multiple online inquiry and appeal systems and coding structures of files to interpret data used in responding to appeals.
Knowledge of systems used to support the Medicare enrollment exchange processes including CMS regulations, policies and procedures pertaining to Capital BlueCross, Avalon and transfer of enrollment to all applicable vendors.
A minimum of two years customer service or correspondence experience or experience/training in a writing-intensive role is required
Hgh School degree and demonstrated work experience of no less than two years is required

Nice To Haves

Extensive experience with customer interaction preferred
Bachelors degree in business administration, health care administration or a related field or equivalent demonstrated work experience of no less than two years

Responsibilities

Researches and analyzes customer redetermination and reconsideration requests and provider appeals. Determines appropriate action by reviewing and interpreting applicable policies/procedures and CMS and HHS guidance that are within established regulatory requirements. Utilizes the PC, manuals, online reference materials, imaging technology, the appeals system, the PBM system to obtain benefits, enrollment, claims and appeals case information. Appeal functions also include handling Medicare Part C and Part D grievances, case preparation for submission to the QIO (Quality Improvement Organization), case preparation for submission to the IRE (Independent Review Entity) and handling quality of service and quality of care complaints. Prepares case files and attends administrative law hearings, when required.
Ensures the satisfactory resolution of routine and complex appeals including, but not limited to, benefits, claim filing and processing, collection issues, enrollment discrepancies, legal requests, Medicare Secondary Payer, billing and payment requests, reinstatements, conversions, refunds, new enrollment, transfer situations, disability certifications, handicapped dependents, for all lines of Medicare Part C and Part D business administered and supported by Capital BlueCross and Avalon.
Conducts specific job related instructional sessions as requested by management in accordance with CMS and HHS guidance.
Respond to customers appeals via telephone, correspondence, on-site, Fax, Secure IT, E-mail and personal interviews from individual customers, group administrators, providers, Capital BlueCross personnel, Host Plan personnel, attorneys, and outside entities working on the customer's behalf. Interacts with the PBM and the IRE to resolve cases.
Monitors appeals via utilizing various system generated reports for accurate and timely resolution to ensure customer satisfaction and compliance with all applicable quality, and timeliness guidelines. Provides clear and concise instructions to the appropriate Plan area, in the approved format (e.g., electronic, on-line or hard copy forms, telephone contact) for the resolution of the issues.
Contacts the appropriate internal/external entities (e.g., groups, providers, Marketing, Legal, Host Plans, PBM, IRE, QIO, ALJ, CMS etc.) to obtain information and initiate necessary action.
Enters all information necessary to update the Facets appeal module, or Work Desk when appropriate, for tracking appeals action and status. Utilizes the system to obtain background information and prevent duplication of effort.
Reports to management appeal trends that may indicate processing problems, lack of documentation or appropriate information, including but not limited to, claims, enrollment areas, benefits, pharmacy services, policies and procedures.
Assists/participates with Marketing personnel and the broker community in the support of customer needs by researching and communicating information to other Company personnel or directly to the customer. May attend or participate in marketing related activities as a representative of Capital Blue Cross (e.g., open enrollment, on-site visits, etc.).
Performance standards, business metrics and process improvements to include: Complete all CMS required acknowledgements related to training and coaching: Complete ongoing training to stay abreast of product, service and policy changes: Improve quality of work on a daily basis by learning and employing new skills: Recognize, document and alert management of trends in customer service inquiries and appeals: Conducts oneself in a manner consistent with the values of the organization