Resp & Qualifications
PURPOSE:
The Appeals Specialist I is responsible for the initial analysis of appeals correspondence, and determination of next steps for Commercial and Government Program lines of business. Responsible for collecting, organizing and tracking information to facilitate and expedite processing of appeals received from a variety of sources.
ESSENTIAL FUNCTIONS:
- Prioritize, research and analyze all pertinent information in preparation of an appeal request. Access the appropriate database to implement accurate and timely entry of appeal or reconsideration correspondence and updates the appropriate referral source communication system. Assigns cases to the nurse for research and completion. Performs file coordination activities including, but not limited to filing of all active files, purging of files for transport to off-site storage.
- Utilizes professional written and verbal communications to assist in responses of all appeals 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 Specialist II and III with unit projects and other duties related to the appeals and reconsideration process. Communicates with Supervisor to offer feedback regarding continuous improvement of unit workflow and processes. Actively participates in monthly meetings and discussions regarding quality appeal research, data entry and to problem solve any issues regarding the appeal intake/entry process.
QUALIFICATIONS:
Education Level: High School Diploma.
Experience: 3 years experience in settings such as managed care, health care or insurance payor environment.
Preferred Qualifications:
College Degree.
Knowledge of CareFirst system, Member/Provider Service, Claims or Care Management experience a plus.
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.
- 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.
Department
Department: Maryland Medicaid
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.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Closing Date
Please apply before:05/18/2022
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