Appeals Specialist

Summary

The Appeals Specialist independently investigates, documents, and processes member and provider appeals across assigned IBX lines of business in accordance with IBX policies and procedures and applicable federal, state, contractual, and accreditation requirements. The Specialist validates the appeal request, classification, appellant authority, regulatory timeframe, member eligibility, benefits, claims, authorization history, denial rationale, and supporting documentation. The Appeal Specialist is responsible for building a complete and audit-ready case file, investigating the appellant argument inclusive of application of the correct benefit, policy, and procedural requirements. The Appeal Specialist renders administrative determinations within delegated authority or routes cases to the correct team for review and determination. The Appeal Specialist is responsible for creating accurate, compliant determination letters, initiating and monitoring required effectuations, and completing all case activities within established quality and timeliness standards.

Responsibilities

·       Manage assigned appeals from case receipt through investigation, determination, notification, effectuation, and closure while meeting all regulatory and internal turnaround times.

·       Validate accuracy of cases assigned using the appropriate policies and procedures applicable to the member’s benefit plan.

·       Accurately identify the substance of the appeal and reconcile discrepancies among the appeal request, denial letter, claim, authorization, and case-system information. Escalate unclear or incorrectly routed cases before compliance is affected.

·       Investigate the appellant argument by interpreting applicable member benefits, Evidence of Coverage, benefit booklets, Summary Plan Descriptions, claims history, Explanation of Benefits, authorization records, denial rationale, medical and claim-payment policies, CMS guidance, state requirements, and IBX operational reference materials.

·       Build a complete case file to support the investigation and determination of the appeal in accordance with IBX documentation standards.

·       Prepare clear case notes, claim summaries, case narratives, and decision rationales that accurately explain the issue, research performed, evidence reviewed, applicable benefit or policy provisions, determination, and required next steps.

·       Prepare complete external review packages, submit them through the designated process within required timeframes, monitor for determinations, and document the outcome and follow-up actions.

·       Communicate professionally with members, authorized representatives, providers, vendors, and internal business partners by telephone and in writing; conduct required outreach; and document each communication accurately in the appropriate system.

·       Draft and validate acknowledgment, request-for-information, dismissal, and determination correspondence using the correct approved template, addressee, appeal rights, timeframe, rationale, benefit or policy reference, and required regulatory language.

·       Initiate overturned case effectuation or claim adjustment requests, monitor completion, reconcile outstanding tasks and ticklers, and escalate delays that present member, financial, quality, or compliance risk.

·       Use IBX appeal and supporting systems effectively, including the case management system, claims and eligibility platforms, authorization systems, document repositories, communication tools, policy libraries, and applicable vendor or external review portals.

·       Manage daily inventory, prioritize expedited and aging cases, identify work at risk, meet productivity and quality expectations, and promptly escalate system, access, documentation, workload, or process barriers.

·       Perform other duties as assigned.