CareFirst BlueCross BlueShield Appeals Specialist, III (MD Medicaid/Medicare) in Owings Mills, Maryland
Resp & Qualifications
The Appeals Specialist III will be responsible for assisting the Manager, Supervisors, and Business Analysts or Operations Coordinators with unit projects, quality audits, and overall operational functions. Responsible for the initial analysis of appeals correspondence, determining next steps, collecting, organizing and tracking information to facilitate and expedite processing of appeals received from a variety of sources. Serves as subject matter expert. Able to provide short term or interim coverage for high level complicated cases that require detailed research and analysis.
Determines appropriate action required by prioritizing, researching and analyzing information to successfully complete initial inquiries and be accountable for accurate and timely case entry and assignment. Leads a team in the analysis of existing business processes and systems to identify, document, elevate the presence of risks and trends within systems and processes that may be non-compliant with requirements for proper appeals handling. Analyzes and researches necessary information for high profile cases in a timely or expeditious manner including written responses to governmental agencies.
Consistently develops accurate professional written communications and verbal interaction with internal and external stakeholders. Reviews and researches complicated or high profile correspondence with Supervisor as necessary. Will articulately present and discuss compliance as needed and exhibit sound judgement in determining a recommendation or solution to an identified problem.
Independently researches contractual benefits, limitations & exclusions and claims related cases as a subject matter expert to assist medical professional staff in performing the review of appeals and reconsiderations. A subject matter expert for internal stakeholders, particularly in specialized appeal areas. Recognizes and acknowledges time sensitive or escalated requests and tasks and acts as a liaison for other departments and company stakeholders to complete Regulatory complaints, internal and external audits and other projects as needed.
Provides support and acts as a trainer and mentor to entry level associates including Appeals Specialists I & II. Designs and provides effective training programs for internal customers who need education on the appeals process. Develops and provides information, training and education for appeals associates at Staff, R &T and Nurse Forums. Performs other duties such as committee work and special projects.
Education Level: High School Diploma
Experience: 5 years experience in settings such as managed care, health care or insurance payor environment
3 years experience in Clinical Appeals and Analysis Unit including 2 years experience as an Appeals Specialist II
Preferred Qualifications: College Degree
Knowledge of CareFirst system, Member/Provider Service, Claims or Care Management experience a plus.
Knowledge, Skills and Abilities (KSAs)
PC skills such as the ability to create Power Point presentations and perform more advanced Excel spreadsheet functions.
Consistent High Performer
Must be able to demonstrate ability to provide coverage for CAU specialty case processing.
Demonstrated ability to lead, train, coach and mentor less experienced team members.
Must be able to evaluate demands on time, work in fast paced environment and establish and manage appropriate priorities.
Thorough understanding of the appeals process and ability to work independently in researching complex issues.
Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Department: Maryland Medicaid and DSNP
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 11/13/21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship