Note: The job is a remote job and is open to candidates in USA. Highmark Inc. is a health insurance organization. The Appeals Analyst reviews and manages member or provider grievances and appeals, ensuring regulatory compliance, coordinating investigations and resolutions, and documenting results for involved parties.
Responsibilities
- Review inquiries to determine if they meet definition of appeal/grievance
- Request and review all related relevant documentation and assemble case file
- Coordinate resolution results and relay investigative results with all involved parties
- Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends
- May support the Quality Assurance, Appeal and other quality committees
- Other duties as assigned or requested
Skills
- High School Diploma or GED
- 3-5 years of relevant, progressive experience in the area of specialization. Exempted experience requirements effective August 2016
- Knowledge of multiple processing systems and workflows
- Knowledge of claims processing methodologies
- Ability to interpret all government regulations
- Knowledge of company products
- Excellent organizational skills
- Strong verbal and written communication skills
- 0% - 25%
- Physical work site required Yes
- Lifting: up to 10 pounds Constantly
- Lifting: 10 to 25 pounds Occasionally
- Lifting: 25 to 50 pounds Occasionally
- Experience in Customer Service or a related field
Company Overview