Appeals Analyst-Kansas City area

Work At Home - Missouri

Full time

R6966

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:

Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute

Annual incentive bonus plan based on company achievement of goals

Time away from work including paid holidays, paid time off and volunteer time off

Professional development courses, mentorship opportunities, and tuition reimbursement program

Paid parental leave and adoption leave with adoption financial assistance

Employee discount program

Job Description Summary:

Processes complaints, grievances and appeals from member and providers, and other projects as assigned. Appeal Analysts are allowed to work from home with management approval, which is generally based upon business needs and employee performance

Job Description

• Gather and review information necessary to determine the appropriate resolution of complaints, first and/or second level grievances and appeals (e.g., from Blue KC systems and personnel, providers, members, external medical review organizations).

• Document work according to department Standard Operating Procedures (SOPs), such that another Appeals Analyst could reasonably come to the same conclusion.

• Develop timely, accurate responses to complaints, grievances and appeals. Responses must comply with all federal, state, Blue Cross and Blue Shield Association, accreditation requirements and department Standard Operating Procedures (SOPs).

• Communicate follow up actions to operational areas (e.g., claim adjustment for overturned decisions) and follow up to ensure actions are completed timely and accurately.

Minimum Qualifications

• Bachelor’s degree in business, finance, accounting, law, health care administration, or other relevant academic discipline; OR four (4) years relevant experience in the health insurance industry

• 1-3 years of experience at a health insurer researching and responding to customer claim / benefit issues, or a related role providing a working knowledge of health plan benefits, major business systems and operational processes (e.g., Claims Processing, Member Services, Customer Service).

• Ability to effectively communicate with a broad range of individuals and groups, including members, providers and Blue KC employees and senior management on issues related to a complaint, grievance or appeal.

• Ability to compose professional business correspondence, including communication of complex processes and decisions

• Working knowledge of member health benefit certificates.

• Thorough knowledge of major BCBSKC lines of business (e.g., local insured, BlueCard), business systems (e.g., Facets, ITS Host and Home) and operational processes (e.g., Claims Processing, Member Services, Customer Service).

• Working knowledge of BCBSKC medical policies.

• Working knowledge of federal and state, Blue Cross and Blue Shield Association, and accrediting body requirements related to complaints, grievances, and appeals.

• Thorough knowledge of BCBSKC member health benefits certificates.

Preferred Qualifications

• 2-4 years of experience processing complaints, grievances and appeals at a health insurer.

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.

Important Recruiting Update:

Beginning October 11 through late December our recruiting sites will undergo a planned transition. During this time, fewer positions may be posted, and some recruiting processes may take longer than usual. We appreciate your patience and encourage you to check back for future opportunities.

EOE/Veterans/Disability

Affirmative Action Employer

E-Verify Participation (https://bluekcmemberportal.azureedge.net/pdf/2024/E-Verify\_Participation\_Poster\_Eng\_Es.pdf)

Equal Employment Opportunity/Nondiscrimination/Affirmative Action Policies

IER Right to Work (https://www.e-verify.gov/sites/default/files/everify/posters/IER\_RightToWorkPoster%20Eng\_Es.pdf)

FMLA

Employee Polygraph Protection Act (https://www.dol.gov/whd/regs/compliance/posters/eppac.pdf)