Appeals Specialist I or II DOE
Cambia Health Solutions

Job Info

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Appeals Specialist I or II DOE

Remote in WA, ID, OR, and UT - Applicants residing outside those states will not be considered.

Primary Job Purpose:

Handles requests for Provider Billing Disputes and Appeals. Includes analysis, preparation, evaluation of prior determinations, coordination of clinical review if needed, decision making, notification, and completion. Follows guidelines outlined by subscriber or provider contracts, company documents, government mandates, other appeals regulatory requirements and internal policies and procedures. Provides assistance to members, providers, insurance companies, and attorneys or others regarding benefits and claims. Does not make final clinical decisions but has access to licensed health professionals who conduct clinical reviews for appeals.

Normally to be proficient in the competencies listed below:

Appeals Specialist I would have a high school diploma or GED and a minimum 4 years' experience in Regence Customer Service, Claims, or Clinical Services or equivalent combination of education and work experience.

Appeals Specialist II would have a coding certification through AAPC or AHIMA, and a high school diploma or GED and a minimum 4 years' experience in Regence Customer Service, Claims, or Clinical Services or equivalent combination of education and work experience.

Minimum Requirements:

• Excellent verbal and written communication skills.
  
• Intermediate digital literacy (e.g. Microsoft Word, Excel, Outlook) and experience with Regence systems.
  
• Knowledge of medical terminology, anatomy and coding (CPT, DX, HCPCs).
  
• Knowledge of Regence claims processing and clinical services operations.
  
• Proven initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing a course of action.
  
• Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all aspects of internal and external contacts.
  
• Ability to present complex medical and reimbursement information to others and to be diplomatic and persuasive regarding health plan benefits, claims and eligibility.
  
• Ability to switch from one task or type of work to another as the business needs require.
  
• Ability to effectively prioritize work to meet strict timelines while maintaining quality and consumer centric focus.
  

Responsibilities:

• Appeal Intake - Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal. Document information in appropriate system.
  
• Appeal Analysis - Review claim coding and claim processing history, medical policy and reimbursement policies, regulatory and legal requirements, benefit contracts, and/or provider contracts. Collect and catalogue supporting documentation and formulate an appeal recommendation. Document information in appropriate system. Apply knowledge and experience to answer a variety of increasingly complex inquiries from members, providers, and provider representatives. Collaborate effectively with coding specialists, appeal nurses, physician reviewers, and others as necessary to reach timely decisions on appeals.
  
• Decision & Closure - Make non-clinical appeal determinations as permitted by department business processes and guidelines. Follow department's processes to receive a clinical review and decision from licensed health professionals. Present complex cases to appeal panels, document decisions, communicate determinations to members, providers or their representatives. Document information in appropriate system(s).
  
• External review process - Oversee set-up of appeals for external review organizations, including document collection and coordination, communication with all parties, and other responsibilities as an intermediary between the provider and the external review organization. Ensure external review information is documented in appropriate system. Prepares letters and cases for external review as needed. Implement external review decisions.
  
• Interpersonal and Communication - Provide information, education and assistance to members, providers, and their representatives. Facilitate the member's or provider's' understanding of the appeal process and of the information necessary to effectively process an appeal. Be a courteous advocate to the member or provider when requesting supporting information. Work cooperatively and effectively across all business areas to resolve.
  
• Systems and data - Track appeals in appropriate systems and assist in the maintenance of files. Assist with compilation of reports on appeals, including trends, number of cases, decisions, suggestions for process improvement, types of appeals, and compliance with timelines.
  
• Support, apply and promote Provider or Member Appeal Policies & Procedures.
  
• Adhere to dependability, customer focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all work.
  
• Manage a defined caseload within department productivity and quality expectations and provide back up for the team.
  
• May perform as expert witness during any level of appeal, regarding policies, procedures and member or provider appeal rights.
  
• Meet timeliness standards as set forth through department policies and procedures, subscriber summary plan descriptions, performance guarantees, and regulations.
  

Work Environment:

May be required to work overtime.

Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.

Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.

If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.

Information about how Cambia Heath Solutions collects, uses, and discloses information is available in our Privacy Policy.

This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards.

We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.

If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.

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