UM Appeals Analyst - MAC

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

1d•$63,000 - $84,420

About The Position

This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators. The incumbent prepares/presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings. Incumbent will mentor more junior staff by responding to questions and sharing expertise. Incumbent will adhere to all regulated processes and timeframes in accordance with the 1st, 2nd level and Special Process UM Appeal workflows.

Requirements

High School Diploma/GED required.
Requires minimum of 5 years healthcare industry or operations experience.
Requires minimum 3 years direct customer service experience, preferably in a medical support related position.
Requires knowledge of medical terminology.
Requires strong oral and written communication skills.
Requires ability to make sound decisions under the direction of the supervisor.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Microsoft Outlook).

Nice To Haves

Prefer experience with prior appeals handling and correspondence.
Prefer knowledge of UCSW, Medical Policy guidelines, and Care Radius.
Prefer knowledge of contracts, enrollment, billing, & claims coding/processing.
Prefer knowledge of Managed Care principles.
Prefer the ability to analyze and resolve problems with minimal supervision.

Responsibilities

Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
Handles initial screening for UM Appeals requests from physicians/members/facilities/authorized representatives via incoming calls or correspondence based on workflows.
Manage correspondence of toll-free UM Appeal hotline and UM Appeal fax server. This includes speaking with various customers, education, triaging calls, and disseminating information during business hours. In addition, calls to the appellant, education, triaging incoming faxes, and assigning appeals during business hours.
Interacts with and supports Medical Directors.
Schedule and arrange peer to peer discussions with physicians and our Horizon Medical Directors.
Prepare, document and route cases in appropriate system for clinical review.
Prepares, presents, and schedules cases for the Member Appeals Committee (MAC) Committee & Expedited Subcommittees.
Responsible for the comprehensive explanation of previous denials, the scope of coverage, applied criteria, and how the case was handled.
Responsible for addressing questions posed by the appellant or committee and administrative support of completing the appeals process.
Responsible for partnering with all parties that handled the case to facilitate fact gathering and to gain a thorough understanding of the determination and appropriate benefits.
Conducts and provides root cause analysis to avoid future appeal occurrences.
Works with supervisor to develop and deliver refresher training to business teams on proper appeal referral, handling, and MAC case preparation.
Assists in the development of junior staff through mentoring, coaching and assisting them in the proper handling of appeal cases.
Act as a mentor to junior staff by responding to questions and sharing expertise.
Assists with running and validating reports for the team.
Perform other relevant tasks as assigned by Management.