What are the responsibilities and job description for the Appeals Specialist position at Independence Blue Cross Careers?
Summary:
The Appeals Specialist investigates appeals and grievances in accordance with established policies and regulations. The Appeals Specialist is also responsible for the preparation of case files for both clinical and/or administrative review.
Responsibilities
· Researches the history relevant to the case, including the member’s enrollment and eligibility status, provider status, benefit plan and circumstances surrounding denial of services or rejection of claims.
· Establish and document case category, sub-category, and root cause accurately.
· Verify validity and classification of case and escalate when needed.
· Communicates with members, representatives, and/or providers verbally and/or in writing according to unit policy and within the established timeframes.
· Document needed case details, including communications, within the relevant systems completely, clearly, and accurately.
· Communicates effectively and professionally with internal and external resources to coordinate and investigate information as it relates to the case.
· Ensures case documents are stored according to unit guidelines and submitted timely for Q/A purposes.
· Organizes case documentation for external review per regulatory guidelines.
· Manage caseload and ensure all tasks are completed within internal guidelines.
· All other duties as assigned.
Education
· An associate degree and/or related experience with customer service, claims, and/or case handling.
Experience
· Experience in appeals triage function preferred.
- Working knowledge of plan products, benefits, and claims preferred.
- Demonstrated ability to research and handle complex issues.
- Ability to collaborate with a variety of individuals both internally and externally.
- Writing, editing, and proofreading skills.
- Excellent customer service, organizational, time management and communication (verbal and written) skills.
- Working knowledge of Microsoft Word, Excel, and Outlook a plus.
Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
