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$21.53–$32.30/hr

Appeals Analyst

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Full-time Remote 17d ago

Location:

US

Company:

Highmark Inc. is a national, blended health organization offering a range of health-related services including insurance and health care delivery.

Summary:

The Appeals Analyst coordinates the resolution of grievances and appeals, ensuring compliance with regulatory requirements. Applicants need a high school diploma and 3-5 years of relevant experience.

Requirements:

Hard Skills: Knowledge of multiple processing systems and workflows, Knowledge of claims processing methodologies, Ability to interpret all government regulations, Knowledge of company products, Excellent organizational skills, Strong verbal and written communication skills

Credentials: High School Diploma or GED

Experience: 3-5 years of relevant, progressive experience in the area of specialization

Job Description:

JOB SUMMARY

This job reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results.

ESSENTIAL RESPONSIBILITIES

  • Review inquiries to determine if they meet definition of appeal/grievance.
  • Request and review all related relevant documentation and assemble case file.
  • Coordinate resolution results and relay investigative results with all involved parties.
  • Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends.
  • May support the Quality Assurance, Appeal and other quality committees.
  • Other duties as assigned or requested.

EDUCATION

Required

  • High School Diploma or GED

Substitutions

  • None

Preferred

  • None

EXPERIENCE

Required

  • 3-5 years of relevant, progressive experience in the area of specialization. Exempted experience requirements effective August 2016.

Preferred

  • Experience in Customer Service or a related field

LICENSES or CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • Knowledge of multiple processing systems and workflows
  • Knowledge of claims processing methodologies
  • Ability to interpret all government regulations
  • Knowledge of company products
  • Excellent organizational skills
  • Strong verbal and written communication skills

Languages (Other than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Occasionally

Pay Range Minimum: $21.53

Pay Range Maximum: $32.30