Appeals Analyst

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results.

ESSENTIAL RESPONSIBILITIES

Review inquiries to determine if they meet definition of appeal/grievance. Request and review all related relevant documentation and assemble case file. Coordinate resolution results and relay investigative results with all involved parties. Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends. May support the Quality Assurance, Appeal and other quality committees. Other duties as assigned or requested.

EDUCATION

Required High School Diploma or GED Substitutions None Preferred None

EXPERIENCE

Required 3-5 years of relevant, progressive experience in the area of specialization. Exempted experience requirements effective August 2016. Preferred Experience in Customer Service or a related field LICENSES or

CERTIFICATIONS

Required None Preferred None SKILLS Knowledge of multiple processing systems and workflows Knowledge of claims processing methodologies Ability to interpret all government regulations Knowledge of company products Excellent organizational skills Strong verbal and written communication skills Languages (Other than English) None Travel Requirement 0% - 25%

PHYSICAL, MENTAL

DEMANDS and

WORKING CONDITIONS

Position Type Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Occasionally Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required

Yes Lifting:

up to 10 pounds

Constantly Lifting:

10 to 25 pounds

Occasionally Lifting:

25 to 50 pounds

Occasionally Disclaimer:

The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement:

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$21.96

Pay Range Maximum:

$32.95 Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America's largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health's 35,000 employees serve millions of customers nationwide through the nonprofit organization's affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health's businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.