Note: The job is a remote job and is open to candidates in USA. Highmark Inc. is a health insurance company seeking an Appeals Analyst to review and manage member and provider grievances and appeals. The role involves determining case eligibility, assembling documentation, coordinating investigations and resolutions, ensuring regulatory compliance, and supporting process improvement efforts.
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
- Experience in Customer Service or a related field
Company Overview