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Senior Appeals Specialist

1 month ago

Philadelphia, Pennsylvania, United States Independence Blue Cross Full time
Job Summary

The Senior Appeals Specialist is responsible for investigating appeals and grievances in accordance with established policies and regulations. This role involves preparing case files for clinical and administrative review, as well as making outreach calls to members, providers, and representatives to acknowledge receipt of appeal requests.

Key Responsibilities
  • Investigate clinical appeal requests, reviewing medical policy, guidelines, member handbooks, benefits, claims, pre-authorizations, and medical records to identify the basis of the original decision.
  • Make outreach calls to members, providers, and representatives to acknowledge receipt of appeal requests and request medical records necessary for review.
  • Prepare case documentation, including medical policy, guidelines, member handbooks, claims, and medical records, and package for decision.
  • Document entire investigation in the Appeals Management System and utilize multiple Independent Review Organization (IRO) portals for submission of clinical appeals.
  • Create appeal determination letters with a detailed description of the nature of the appeal, medical policy, and benefits.
  • Initiate effectuation requests for overturned appeals and follow through until completion.
  • Regularly contact internal Medical Directors regarding appeal decisions, sign-offs, and input on complex clinical cases.
  • Regularly contact external vendors to obtain additional information, records, policy, and correspondence from the initial determination.
  • Comply with timeliness and quality standards regulated by State and Federal entities, including the Pennsylvania Insurance Department and the NJ Department of Banking and Insurance.
  • Identify trending appeal issues and initiate discussions across the team and/or to management for review and analysis.
  • Provide support to Triage and Appeals Specialists with questions on complex cases that potentially require medical review.
  • Perform quality checks and reviews.
Requirements
  • High School diploma; undergraduate degree preferred.
  • A minimum of 2 years working in the appeals department with demonstrated proficiency in attention to detail and accuracy in appeal cases.
  • Knowledge of corporate medical policy and procedures, HMO and PPO benefit structures, and proficiency in Microsoft Office products, database, spreadsheets software, and precertification and claims systems.
  • Excellent interpersonal skills to interact with internal and external customers.
  • Self-motivated, highly organized, detail-oriented, and member advocate.
  • Excellent written and communication skills.