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Job Summary

The Appeals Analyst reviews and responds to appeals and inquiries from members, providers, authorized representatives, insurance departments, and/or other regulatory bodies regarding adverse benefit determinations within the timeframes set forth in both federal and state law. This position must favor neither the Company nor the member and must exercise independent judgment in determining whether an adverse benefit determination was legal, appropriate, impartial and in accordance with the enterprise’s obligation under the applicable contract.

Requirements

EDUCATION

Bachelor’s degree in related field. In lieu of degree, five (5) years' relevant experience will be considered in addition to the experience requirements listed below.

EXPERIENCE & KNOWLEDGE

Minimum three (3) years' healthcare grievances, appeals, claims processing, claims research, customer service or related legal experience.
Working knowledge of insurance products, policies, procedures and/or claims processing preferred.
Experience using Microsoft Office i.e. Word and Excel.

ESSENTIAL ABILITIES
Sound Judgement
HIPAA Confidentiality
Legal Confidentiality
Taking Initiative

Skills

• Analytical Decision Making • Analytical Problem Solving • Business Compliance • Claims Management System • Continuous Learning • Critical Thinking • Cross-Functional Communications • Customer Relationship Management (CRM) • Data Analysis • Law • Management Techniques • Microsoft Excel • Microsoft Office • Needs Assessment • Sound Judgment • Time Management

Responsibilities

• Analyzes and responds to inquiries, complaints and/or concerns from members, providers, regulatory bodies and/or attorneys. • Communicates medical coverage policy, processing guidelines and policy language with internal and external sources to facilitate, resolve, and respond to appeals within URAC/legal timeframe. • Maintains administrative records of all case files, logging the appeal for each inquiry, and requesting relevant information from appropriate internal and external sources. • Maintains a thorough knowledge of the benefit plans. • Monitors the status of appeals. • Performs other duties as assigned. • Prepares written analysis that communicates facts and determinations for appeal responses within the timeframe. • Recommends changes to the appeals process and contract language, as necessary, to minimize legal and regulatory liability. • Utilizes current information from medical coding sources to ensure guidelines used in appeals are clear and concise.

Certifications

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.