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Appeals Technical Analyst

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Appeals & Grievances
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711 Total Views
Bring your drive for excellence, team orientation and customer commitment to Independence; help us renew and reimagine our business and shape the future of health care. Our organization is looking to diversify, grow, innovate and serve, and we are looking for committed, empowered learning-oriented people to join our team. If this describes you, we want to speak with you.

The Appeals Technical Analyst's duties include, but are not limited to:

  • Performs daily quality assessments for all function areas of the Appeals and Grievances Department to assure the integrity of processes – for commercial lines of business.
  • Reviews include assessments of the decision-making process through the life of the appeal and assuring that compliance and quality is met
  • Identifies deficiencies in individual, departmental, and external associate or other teams if needed
  • Performs periodic internal audits and represents Appeals on formal audits assists department including case preparation.
  • Previews cases, identifies deficiencies, facilitates resolutions
  • Develops department action plans regarding compliance with Mgt. approval
  • Monitors effectiveness of desk level procedures and guidelines
  • Maintains a thorough understanding of the respective departmental and corporate policies and remains current on all functions performed by each unit within the department: administration and determination, and adjudication
  • Assists team members and supervisors with inventory and case questions
  • Reviews daily inventory and ensures cases due are compliant.
  • Serves as a subject matter expert for the department and business partners
  • Trains and peer-coaches
  • Trains new hires on the QA process, peer-coaches staff as needed on areas identified as needing improvement
  • Creates and presents training material for staff and business partners as needed
  • Works with eternal teams to improve process and find opportunities to reduce appeals, such as Customer Service, Claims, CMC and Medical Policy teams.
  • Performs other duties as assigned
Position Qualifications:
  • Bachelor's degree and five years progressive experience in Member Appeals, Claims Services, Member Services, Care Management, audit functions or equivalent
  • Requires excellent research and investigative skills, strong interpersonal skills, and the ability to work effectively with all associate and management levels
  • Excellent oral, written communication and organizational skills are essential
  • Demonstrated analytical experience and ability to work independently
  • Must be detail oriented and possess the ability to synthesize complex information
  • Experience with regulatory/accreditation requirements preferred
  • Demonstrated knowledge of Microsoft Excel, Word, Outlook, and SharePoint. Comprehensive knowledge of corporate benefit plans, medical policies, and systems and applications including, OSCAR, INSING, and 4UM

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. 

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