Sr Commercial A&G Res Special

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.  

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”    

The Senior Appeals & Grievances Resolution Specialist is responsible for identifying, reviewing, and resolving all appeals and providing notification to customers to ensure compliance with organizational and regulatory requirements. Appeals submitted to include but not limited to; enrollment, billing, benefits, and claims for various types of coverage plans offered by Capital BlueCross. Knowledge of Medicare, PPACA, NCQA, Act 68, CHIP, FEP, ERISA, prescription, dental, vision, Chiropractic, Disease Management, Benefits Management, and other programs administered/supported by Capital Blue Cross.

Responsibilities and Qualifications

Duties and Responsibilities:

• Serves as a technical resource to team and may be assigned to work on projects in support of appeal and grievances policy and/or managed care/ACA initiatives.
• Act as subject matter expert regarding grievances and appeals.
• Investigates and reviews member and provider grievances and appeals. Generally, works on issues that are of a complex nature.
• Serves as an internal resource for lower-level appeal specialists and staff.
• Extrapolates and summarizes information for clinicians, consultants, and other external review.
• Prepares recommendations along with supporting detail to either uphold or deny appeals.
• Serve as liaison between members, provider regulatory agencies and internal staff.
• Correspond with key individuals regarding grievance and appeal decisions.
• Consults with other internal areas and external vendors to resolve high profile, complex appeals and/or complaints.
• Participates in projects impacting development, interpretation, and implementation of policy or other managed care initiatives.
• Provide desk mentoring for new staff and staff undergoing cross-training.
• Provide functional training for peers, as required by workload.
• Conducts specific job-related instructional sessions as requested by management.
• Use communication to create awareness and acceptance of change within AGR. Support the management team in developing an understanding of change to drive acceptance.
• Provide mentoring and guidance within the department and AGR to facilitate knowledge transfer, develop the skill set of peers, and develop consistency and standards across the department.
• Research and analyze all customer appeals. Perform case development to include contacting appellants verbally and in writing, gathering information, communicating disposition of case and documenting interactions. Contact the appropriate internal/external entities (e.g., groups, providers, Marketing, Legal, Host Plans, etc.) to obtain information and initiate necessary action. Determine appropriate resolution by reviewing and interpreting applicable policies/procedures that are within the established regulatory requirements. Utilize all processing manuals, online reference materials, and systems to obtain benefits, enrollment and claim information for appeal resolution. Respond to customer appeals via required contact methods as outlined in procedures in a clear and concise manner.
• Monitor individual and department appeal cases to ensure accurate and timely resolution. Ensure customer satisfaction and compliance with MTM (Member Touchpoint Measures), PPACA, ERISA, NCQA and Act 68 quality, and timeliness guidelines.
• Complete ongoing and/or mandatory training to stay abreast of current appeal process and policy changes.
• Represent the department in a professional manner and adhere to all department and corporate polices.
• Adhere to consistently meeting all departmental performance goals.

Skills:

• Demonstrates ability to communicate effectively and professionally both verbally and in writing with all levels of internal/external personnel to respond to customer inquiries ranging from routine to complex and involving sensitive subject matter.
• Demonstrates ability to understand and interpret detailed policies and procedures and to be able to apply them to various situations. This includes thorough understanding of Capital’s responsibility to maintain privacy of Protected Health Information as required by the Health Insurance Portability and Accountability Act.
• Demonstrates ability to work independently, be flexible and react appropriately to changing job assignments and work environments.
• Ability to deal with, influence, and communicate with people in an effective, professional and friendly way.
• Demonstrates analytical, organizational, and problem-solving skills in order to accurately and efficiently identify, analyze and respond to customer/provider appeals, as well as identify and analyze trends and discrepancies.
• Familiarity with, or ability to, operate a PC and associated software; Microsoft Office (Word, Excel, etc.), phone equipment, fax, and other department required hardware.
• Demonstrated competency in Windows (Outlook, Teams Word, Microsoft Edge, Excel and PowerPoint)
• Above average reading, writing and arithmetic skills required (reading/math comprehension)

Knowledge:

• Demonstrated subject matter expertise in the appeals department
• Knowledge of benefit programs administered and/or supported by Capital Blue Cross. Includes Medicare Advantage, Medicare Part D and Medicare Supplemental Programs, Dental, Vision, Chiropractic, Prescription Drug, Benefits Management, and Disease Management.
• Knowledge of OnBase, the Pharmacy Benefit Manager and Facets health plan administration processing systems as well as online files for determining enrollment, billing, and benefits. Knowledge of benefits administration policies, customer billing processes, claims processing and general procedures.
• Knowledge of ERISA,NCQA, Act 68, and BCBSA MTM, PPACA, HIPAA, quality and timeliness guidelines and standards to ensure they are consistently met or exceeded
• Knowledge of Enrollment and Billing regulations, policies and procedures pertaining to Capital Blue Cross and transfer of enrollment information to all our vendors
• Knowledge of multiple online inquiry and appeal systems and coding structures of files to interpret data used in responding to appeals.

Experience:

• 1 year experience working within the appeals department.
• 3 years demonstrated work experience.
• 1 year claim experience is preferred.
• Experience working in a quality and production driven environment with demonstrated success in these areas.
• Performance rating must be succeeds or higher.

Education and Certifications:

• High School degree or equivalent.
• Associate degree preferred.

Work Environment:

Sedentary work involves significant periods of sitting, talking, hearing, keying and performing repetitive motions.!!Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.!!Working environment includes typical office conditions.

Physical Demands:

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work 37.5 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

Other:

• Travel Requirements: Some travel into the office during the week and on weekends may be required for training sessions or departmental meetings.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.      And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live