Appeals Analyst – GP

Appeals Analyst – GP

Requirements

• High School Diploma/GED required.
• In lieu of degree applicant must have 5 years of equivalent and relevant work experience.
• Requires seven years of business experience which must include four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
• Healthcare industry experience required.
• Experience in complex claims processing necessary.
• Knowledge of insurance claim and membership systems required.
• Knowledge of medical terminology, COB, Medicare procedures required.
• Knowledge of Claims Policy guidelines required.
• Knowledge of Microsoft Office Suite required.

Responsibilities

• Appears before the Leadership Appeals Workgroup at routinely scheduled hearings to present cases.
• At hearings, responsible for the comprehensive explanation of denials, the scope of coverage, and how the case was handled.
• At hearings, Responsible for addressing questions posed by the Member’s representatives.
• Responsible for contacting all areas of the Company which handled the case in to facilitate fact gathering and to gain a thorough understanding of the benefit contract.
• Should issues addressed by the Leadership Appeals Workgroup be escalated to the DOBI or to the courts, the representative will be required to consult with outside attorneys or the DOBI as needed. May testify on behalf of Horizon BCBSNJ.
• Authorizes administrative exceptions which may involve claim adjustment resulting in payments at higher threshold levels so as to bring closure to the appeal; and conducts daily image queue review to identify appeals and distributes other items as appropriate.
• Conducts detailed root cause analysis, including tracking and trending of errors and omissions that led to escalated complaint and makes recommendations to avoid future appeal occurrences.
• Identifies refresher/enhancement training opportunities for division and/or enterprise employees to reduce and/or eliminate appeals and administrative exceptions. Communicates opportunities to Quality and/or Training departments and works with Supervisors to share knowledge and provide guidance.
• Works with Quality and/or Training to develop and often deliver refresher training workshops to business teams on proper appeal handling.
• Represents Complaints/Appeals function on divisional and enterprise work groups. May be responsible to lead some such groups.
• Assists in the development of new/less experienced staff through mentoring, coaching and assisting them in the proper handing of appeal cases.
• Assists with running and validating reports for the team.

Preferred Qualifications

• Prior appeals handling experience preferred.
• Knowledge of HBCBSNJ complaints and appeals process preferred.
• Knowledge of UCSW preferred.