Company :Highmark Inc.
Job Description :
The job conducts and documents thorough investigations of all complaint and grievance case types, communicating resolution to members in accordance with Center for Medicare and Medicaid Services (CMS) requirements. Requires broad knowledge of plan products, processes and enrollment rules. Responsible for all aspects of nonclinical appeals , up to and including decision making, considering potential impacts to regulatory compliance as well as CMS star ratings. Provides support to clinical appeals, facilitating member verbal and written notification and correct authorization of services. CTM complaints, investigation and response to executive and legislative inquiries also performed by the Appeal Analyst.
- Complete and document thorough investigation of all grievances and appeals. Perform research and evaluate output requirements and formats. Request and review all related relevant documentation and assemble case file. Ensure accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements. Effective and compliant effecutation of appeals. Communicate business operational requirements to internal groups responsible for compliant handling.
- Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff. Compose and complete oral and written responses to all parties. Communicate effectively with colleagues, successfully articulating issues, problems and solutions. Assist in functional walk throughs. May require additional support from more experienced team members.
- Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies. Assist with small to intermediate cross-functional projects and change initiatives involved in the design and delivery of process solutions, implementing strategies and control measures, influencing organizational change related to business processes.
- Participate in process improvement meetings and/or discussions, recommending process process efficiencies and/or strategies fro improvement.
- Ensure quality assurance of appeal/grievance work, assist in development of desktop procedures and/or training materials.
- Other duties as assigned
- High School Diploma/GED
- 3 - 5 years in Appeals or Customer Service
LICENSES AND CERTIFICATIONS
- Customer Service
- Communication Skills
- CMS Regulations
- Claims Processing
Language (Other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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.
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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )
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