Appeals Tech Analyst
o Performs daily quality assessments for all function areas of the Appeals and Grievances Department to assure the integrity of processes – for all lines of business.
o Reviews include assessments of the decision-making process through the life of the appeal and assuring that compliance and quality is met
o Identifies deficiencies in individual, departmental, and external associate or other teams if needed
o Performs periodic internal audits and represents Appeals on formal audits including assisting with case preparation for regulatory and accreditation audits.
o Previews cases, identifies deficiencies, facilitates resolutions
o Develops department action plans regarding findings related compliance with Mgt. approval
o Monitors effectiveness of desk level procedures and guidelines and updates both as necessary
o Maintains a thorough understanding of the respective policies, InterQual criteria and NCQA guidelines and remains current on all functions performed by each unit within the department
o Assists team members and supervisors with inventory management, case status questions, and executive inquiries related to grievances
o Reviews daily inventory and ensures cases due are compliant
o Works with area associates to resolve matters related to expedited cases
o Serves as a subject matter expert for the department and business partners
o Trains and peer-coaches
o Trains new hires on the QA process, peer-coaches staff as needed on areas identified as needing improvement
o Creates and presents training material for staff and business partners as needed
o Works with other business areas and external vendors to identify process improvements and reduce appeals
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o Bachelor's degree and five years progressive experience in Member Appeals, Claims Services, Member Services, Care Management, audit functions or equivalent
o Requires excellent research and investigative skills, strong interpersonal skills, and the ability to work effectively with all associate and management levels
o Excellent oral, written communication and organizational skills are essential
o Demonstrated analytical experience and ability to work independently
o Must be detail oriented and possess the ability to synthesize complex information
o Experience with regulatory/accreditation requirements preferred
o Demonstrated knowledge of Microsoft Excel, Word, Outlook, and SharePoint.
Comprehensive knowledge of corporate benefit plans, medical policies, InterQual criteria, and regulatory and accreditation standards
Diversity, Equity, and Inclusion
At Independence, 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 Independence, 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
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.
Agency Disclaimer
All resumes submitted directly to an Independence Blue Cross 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 Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.