Resp & Qualifications

PURPOSE:
We are looking for an experienced Appeals Specialist in Baltimore, MD or surrounding counties who is willing and able to work largely remote. The incumbent may be expected to work at a CareFirst location based on business needs and work activities/deliverables upon request from their People Leader.

The Appeals Specialist II will be responsible for the initial analysis of appeals correspondence, and determination of next steps, with minimal supervision for Commercial and Government Program lines of business. Responsible for collecting, organizing and tracking information to facilitate and expedite processing of appeals received from a variety of sources. Responsible for more complicated, high level research of cases, and other special projects as well as serving as a subject matter expert.

ESSENTIAL FUNCTIONS:

Independently researches contractual benefits, limitations & exclusions and claims to assist medical professional staff in performing the review of appeals and reconsiderations. Prioritize, research, analyze, and perform accurate data entry for more complex appeals including high profile and escalated cases timely or expeditiously. Performs other duties such as file coordination activities including, but not limited to filing of all active files, purging of files for transport to off-site storage.

Utilizes professional written and verbal communications to assist in responses of all appeals and reconsiderations based on State and Federal requirements for all lines of business. Coordinates and completes vendor auditing duties, as needed. Reviews, researches problematic correspondence and works on special projects with Appeals Nurse or Management.
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Interacts regularly with and responds to internal and external stakeholders, without breaching confidentiality of medical information. Acts as a trainer/mentor for entry level associates. Actively participates in monthly meetings and discussions regarding quality appeal research, data entry and to problem solve any issues regarding the appeal intake/entry process.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Experience:

• 5 years experience in settings such as managed care, health care or insurance payor environment.
  
• 2 years experience in Appeals Management.

Preferred Qualifications:

• College Degree.
  
• Knowledge of CareFirst system, Member/Provider Service, Claims or Care Management experience a plus.

Knowledge, Skills and Abilities (KSAs)

• Research and Problem-Solving Skills.
  
• Ability to lead, train, coach and mentor less experienced team members.
  
• Ability to work both independently and as a member of a team with minimal supervision.
  
• Excellent organizational and analytical skills.
  
• Knowledge and understanding of medical terminology.
  
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.

Salary Range: $44,424 - $81,444

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Appeals and Grievance

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.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

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.

PHYSICAL DEMANDS:

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

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