Appeals Specialist I (Remote)

Resp & Qualifications

PURPOSE:

The Appeals Specialist I is responsible for the initial analysis of appeals and/or grievance correspondence, and determination of next steps for the following line of business: Commercial. The incumbent is responsible for collecting, organizing and tracking information to facilitate and expedite processing of appeals and/or grievances received from a variety of sources. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. The ideal candidate will have previous experience working with appeals and grievances in a healthcare payor organization.

ESSENTIAL FUNCTIONS:

• Prioritize, research and analyze all pertinent information of an appeal and/or grievance request. Access the appropriate technology platform to implement accurate and timely entry of an appeal, grievance and/or reconsideration correspondence and updates the appropriate referral source communication system. Review appropriate benefits and processing guidelines. Submit cases to the nurse for research/decisions and claims department for adjustments and/or claim updates. Performs and manages general mail and/or printing duties and other needs as requested per the needs of the department.
• Utilizes professional written and verbal communications to request additional documentation to assist in response of all appeals and/or grievances based on State and Federal requirements for all lines of business. Interacts regularly with and responds to internal and external stakeholders, without breaching confidentiality of medical information.
• Assists Supervisor and Appeals Specialists II and III with unit projects and other duties related to the appeals, grievance and/or reconsideration processes. Communicates with Supervisor to offer feedback regarding continuous improvement of unit workflow and processes. Actively participates in monthly meetings and discussions regarding quality, appeal and/or grievance research, data entry and helps to resolve any issues regarding the appeal and/or grievance intake and entry/documentation process.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Experience: 3 years experience in settings such as managed care, health care or insurance payor environment.

Preferred Qualifications:

• College Degree.
• Knowledge of CareFirst systems, Member/Provider Service, Claims or Care Management experience.

Knowledge, Skills and Abilities (KSAs)

• Knowledge and understanding of medical terminology.
• Demonstrated problem solving and decision-making skills, including the ability to exercise good judgement.
• Strong organizational and analytical skills.
• Strong verbal and written communication skills using proper grammar and ensuring all correspondence is in line with departmental and reconsideration policies and procedures.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $41,544 - $76,164

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate''s work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case''s facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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