Medicare Appeals Analyst

Capital Blue Cross•Harrisburg, PA

4h•$49,300 - $92,885

About The Position

This position acts as a central point of contact for staff within and outside Appeals and Grievances and provides analytical problem-solving support to Commercial and Medicare Appeals and Grievances staff. The analyst applies knowledge of business practices, systems, procedures, policies, testing tools, and their interrelationships to develop solutions to business problems. The role analyzes other operational areas’ policies, procedures, and performance metrics that affect the department, and supports the development, implementation, maintenance, and monitoring of product and regulatory support. It also coordinates regulatory compliance activities, researches and recommends changes to processing procedures, supports training and documentation, and provides technical support for relevant systems. The position requires three years of Appeals and Grievances experience and advanced experience using a PC and software applications. A bachelor’s degree in a related field or equivalent demonstrated work experience is listed, along with a high school degree and at least three years of demonstrated work experience. The work is sedentary in a typical office environment and requires working 37.5 hours per week. Capital Blue Cross describes a flexible environment that prioritizes employee health and wellbeing, supports community volunteering, and invests in training and continuing education.

Requirements

Three years of Appeals and Grievances experience.
Advanced work experience with a PC and various software applications, including Microsoft Office Suite.
Comprehensive understanding of Capital Blue Cross benefit programs and products, including Medicare and Commercial.
Strong oral and written communication skills, including the ability to present ideas, findings, and recommendations to technical and non-technical audiences and prepare clear documentation.
Ability to work independently and in groups, set priorities, and adjust to changing workload requirements.
Ability to coordinate, prioritize, and organize tasks with minimal supervision.
Demonstrated competency in Windows applications, including Outlook, Word, Internet Explorer, Excel, and PowerPoint.
Ability to navigate FACETS Customer Service and Appeals modules.
Technical acumen to understand supporting configuration and business requirement development.
Knowledge of manual operations, policies, and procedures used throughout the company and their relationship to the department.
Knowledge of Federal and State regulatory requirements surrounding Appeals, including Medicare, Act 68, ERISA, HIPAA, and NCQA.
Knowledge of activities and special processing procedures used in appeals resolution.
Leadership and ethical behavior in an informal reporting relationship.
Strong knowledge of CBC Medicare Advantage and Part D benefit programs.
Bachelor’s degree in business administration, health care administration, information systems, or a related field, or equivalent demonstrated work experience of no less than three years; a high school degree and demonstrated work experience of no less than three years is also specified.
Ability to work 37.5 hours per week.

Responsibilities

Lead departmental process improvements and projects, represent the department on inter-departmental projects including major system enhancements, interpret or translate technical material for day-to-day appeals use, and respond to inquiries and issues from internal staff, other departments, and external business partners.
Perform duties related to the role, including attending meetings, preparing bi-weekly reports, tracking new developments, and researching or resolving specialty inquiries as requested by management.
Research, evaluate, organize, and develop policies and procedures based on identified training needs to facilitate effective processing of Facets inquiries in Appeals and Correspondence Applications.
Serve as the unit’s subject matter expert on appeals module configuration and its interaction with the customer service inquiry module within Facets; prepare detailed exercises and labs for new staff and refresher training.
Assist with preparation and analysis of regulatory and corporate needs for compliance with Federal and State regulations; support data validation and universe pulls through reporting and data analysis; serve as the department subject matter expert for Medicare and commercial compliance activities.
Research and resolve trends identified through independent analysis or as requested by management; conduct peer reviews and document findings, provide audit support, mentor new and cross-training staff, and provide functional training as workload requires.
Evaluate performance metrics and communications from other departments and external vendors to determine departmental impact and required action.
Assist with training programs and coordinate with training staff and management to share resources.
Promote approved company policies and procedures for servicing appeals, arrange supplemental materials, and provide technical support for PC and LAN systems, including Windows, mainframe, Microsoft Office, Visual Basic macros, FACETS, PBM, and other required systems.
Research, analyze, recommend, and implement changes to processing procedures to improve operational effectiveness and meet timeliness requirements.
Support department training and documentation efforts and assess ongoing regulatory compliance, including reviewing laws and regulations and identifying areas requiring change.