Appeals Examiner #00064

Title: Appeals Examiner #00064

State Role Title: Human Resource Analyst II

Hiring Range: $85,000.00 - $100,000.00

Pay Band: 5

Agency: Dept of Human Resource Mgt

Location: Main Street Center

Agency Website: www.dhrm.virginia.gov

Recruitment Type: General Public - G

Job Duties

The Department of Human Resource Management, Office of Health Benefits is seeking a qualified individual to fill the position of Appeals Examiner. This position will be responsible for conducting comprehensive investigations of claim and administrative appeals to ensure fairness, accuracy, and equitable outcomes for appellants. This role includes evaluating clinical appeals and coordinating reviews with contracted independent review organizations. In addition, the position will oversee the intake and resolution of member complaints and manages system transaction audits to ensure adherence to program policies. Also, this position will be responsible for providing guidance to state agency Benefits Administrators, employees, and retirees on relevant policies and procedures, and collaborates with OHB staff on projects and vendor compliance activities.

Minimum Qualifications

Comprehensive knowledge of health benefits policies and practices, including program administration and compliance requirements. Working knowledge of regulations and procedures governing appeals, with the ability to interpret and apply them effectively. Strong analytical skills to evaluate complex information and apply policies and regulations accurately. Proficiency in computer applications to prepare correspondence and reports. Excellent written and verbal communication skills, with the ability to convey information clearly and professionally. Strong organizational and time management abilities, including the capacity to set priorities, work independently, and meet objectives with minimal supervision. Commitment to exceptional customer service, ensuring responsiveness and professionalism in all interactions.

Additional Considerations

Experience with medical claims is preferred. Background in utilization review is highly desirable. Education, certification, or hands-on experience in health benefits administration and/or claims handling is preferred.

Special Instructions

You will be provided a confirmation of receipt when your application and/or résumé is submitted successfully. Please refer to “Your Application” in your account to check the status of your application for this position.

State employees who have been affected by Policy 1.3 Layoff and possess a valid Interagency Placement Screening Form (Yellow Card) or a Preferential Hiring Form (Blue Card) must submit the card BEFORE the closing date for this position. The card may be scanned and attached to the application or faxed to (804) 371-7401. Please include your name and the position number of the fax cover sheet. AMERICORPS, PEACE CORPS, AND OTHER NATIONAL SERVICE ALUMNI ARE ENCOURAGED TO APPLY.

All applicants are subject to a background investigation. The investigation may include: fingerprint checks (State Police, FBI); local agency checks; employment verification; verification of education (relevant to employment); credit checks; and other checks requested by the hiring authority.

“The Department of Human Resource Management is dedicated to recruiting, supporting, and maintaining a competent and diverse work force.”

Equal Opportunity Employer

Department of Human Resource Management

600 East Main Street, 17th Floor
Richmond, Virginia 23219
(804) 225-2131

Contact Information

Name: Derek Mountford

Phone: 804-292-6417

Email: derek.mountford@dhrm.virginia.gov

In support of the Commonwealth’s commitment to inclusion, we are encouraging individuals with disabilities to apply through the Commonwealth Alternative Hiring Process. To be considered for this opportunity, applicants will need to provide their AHP Letter (formerly COD) provided by the Department for Aging & Rehabilitative Services (DARS), or the Department for the Blind & Vision Impaired (DBVI). Service-Connected Veterans are encouraged to answer Veteran status questions and submit their disability documentation, if applicable, to DARS/DBVI to get their AHP Letter. Requesting an AHP Letter can be found at AHP Letter or by calling DARS at 800-552-5019.

Note: Applicants who received a Certificate of Disability from DARS or DBVI dated between April 1, 2022- February 29, 2024, can still use that COD as applicable documentation for the Alternative Hiring Process.