Note: The job is a remote job and is open to candidates in USA. Arkansas Blue Cross and Blue Shield provides health insurance services. The Appeals Analyst independently reviews and responds to appeals and inquiries concerning adverse benefit determinations, ensuring decisions are legal, appropriate, impartial, and compliant with applicable contracts and federal and state law.
Responsibilities
- Analyzes and responds to inquiries, complaints and/or concerns from members, providers, regulatory bodies and/or attorneys
- Communicates medical coverage policy, processing guidelines and policy language with internal and external sources to facilitate, resolve, and respond to appeals within URAC/legal timeframe
- Maintains administrative records of all case files, logging the appeal for each inquiry, and requesting relevant information from appropriate internal and external sources
- Maintains a thorough knowledge of the benefit plans
- Monitors the status of appeals
- Performs other duties as assigned
- Prepares written analysis that communicates facts and determinations for appeal responses within the timeframe
- Recommends changes to the appeals process and contract language, as necessary, to minimize legal and regulatory liability
- Utilizes current information from medical coding sources to ensure guidelines used in appeals are clear and concise
Skills
- Bachelor's degree in related field
- In lieu of degree, five (5) years' relevant experience will be considered in addition to the experience requirements listed below
- Minimum three (3) years' healthcare grievances, appeals, claims processing, claims research, customer service or related legal experience
- Experience using Microsoft Office i.e. Word and Excel
- Sound Judgement
- HIPAA Confidentiality
- Legal Confidentiality
- Taking Initiative
- Analytical Decision Making
- Analytical Problem Solving
- Business Compliance
- Claims Management System
- Continuous Learning
- Critical Thinking
- Cross-Functional Communications
- Customer Relationship Management (CRM)
- Data Analysis
- Law
- Management Techniques
- Microsoft Excel
- Microsoft Office
- Needs Assessment
- Sound Judgment
- Time Management
- Working knowledge of insurance products, policies, procedures and/or claims processing preferred
Benefits
- Remote work arrangement
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