Appeals Specialist
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.
Diversity, Equity, and Inclusion
At AmeriHealth, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At AmeriHealth, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
AmeriHealth 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.
Agency Disclaimer
All resumes submitted directly to an AmeriHealth employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of AmeriHealth and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by AmeriHealth or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.