Service Advocate V (Appeals & Disputes)

This role provides administrative, technical or support functions to a team, department of business unit and is focused on servicing internal customers or supporting units that service providers or external customers.

What You Will Be Doing

• Reviews appeal requests from members and providers in accordance with BCBSF policies and procedures, regulatory guidelines, and timelines. (15%)
• Resolves grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity, ClaimCheck, Utilization Management, and Fee for Service payments within regulatory timeframes for all lines of business except SAO & FEP. (15%)
• Researches and resolves provider data loads. (5%)
• Locates medical records and form CMS-1500 on Enterprise Imaging or Imaginator for clinical review or to verify proper coding (modifiers and procedure codes). (10%)
• Accesses various web-based and other applications to review how claim was originally paid by BCBSF. (5%)
• Researches and documents all issues and findings. (5%)
• Enters appeal or dispute determinations into various BCBSF systems and SQL databases. (5%)
• Follows regulatory requirements as appropriate and corporate values, policies and procedures. (15%)
• Ensures final determination with statement that supports determination is communicated to provider within required timelines. (5%)
• Completes customized correspondence with appropriate statement that supports final determination. (5%)
• Follows strict timelines for communicating final determination. (5%)
• Documents final disposition of dispute into BCBSF systems and SQL databases (5%)
• Facilitates escalated calls and issues from providers and members regarding appeals or dispute decisions. (5%)

What We Require

• 3+ years related work experience combination of transferable experience and education. Experience Details: Service, regulatory, critical inquiry, audit, or compliance

High school diploma or GED

• Experience using Microsoft Office, including Word, Excel and PowerPoint.

• Experience using BCBSF's member benefit booklets, reimbursement, medical necessity, fee for service and ClaimCheck payment concepts, practices, and procedures. Experience using various inquiry and claim payment systems (e.g., Legacy, Diamond, Siebel, PIP, TSO, Convergence, Network Contracting, Medical Coverage Guidelines, CMCA, MBSP, etc.) to research grievance, appeals or disputes.

• Experience entering grievance, appeal or dispute determinations into various BCBSF systems and SQL databases.

• Ability to follow regulatory requirements as appropriate and corporate values, policies and procedures.

• Demonstrated ability to interact with internal and external customers in a highly professional manner.

• Knowledge of ERISA and HIPAA. Knowledge of regulatory agency requirements, as appropriate.

• Ability to work within strict timeframes.

General Physical Demands

Exerting up to 10 pounds of force occasionally to move objects.

Jobs are sedentary if traversing activities are required only occasionally.

Must be able to travel occasionally to multiple locations for work (i.e. travel to attend meetings, events, conferences).

What We Offer

As a Florida Blue employee, you will be at the heart of GuideWell's vision - to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• Additional voluntary benefits available; and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Typical Hourly/Offer Pay Range: $20 - $25

Hourly Pay Range: $20 - $33

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.