Role Description

The Specialist is responsible for identifying, reviewing, and analyzing policy and procedure issues and providing recommendations for solutions. Ensures compliance with organizational, CMS, and other regulatory requirements. Appeals cover topics pertaining to enrollment, billing, benefits, and claims for various types of coverage offered under our SeniorBlue PPO, SeniorBlue HMO, Secure Rx, and Medicare Supplemental Programs. Knowledge of Medicare, CMS regulations, medical, prescription, dental, vision, chiropractic, disease management, benefits management, and other programs administered/supported by Capital BlueCross and Avalon.

• Researches and analyzes customer redetermination and reconsideration requests and provider appeals.
• Determines appropriate action by reviewing and interpreting applicable policies/procedures and CMS and HHS guidance.
• Utilizes various systems to obtain benefits, enrollment, claims, and appeals case information.
• Handles Medicare Part C and Part D grievances and prepares case files for submission to relevant organizations.
• Ensures satisfactory resolution of routine and complex appeals.
• Conducts specific job-related instructional sessions as requested by management.
• Responds to customer appeals via multiple communication methods.
• Monitors appeals for accurate and timely resolution to ensure customer satisfaction.
• Contacts appropriate internal/external entities to obtain information and initiate necessary action.
• Enters information to update tracking systems for appeals action and status.
• Reports appeal trends to management.
• Assists Marketing personnel and participates in marketing-related activities.
• Completes all CMS required acknowledgments related to training and coaching.
• Improves quality of work on a daily basis by learning and employing new skills.

Qualifications

• Demonstrates ability to communicate effectively and professionally both verbally and in writing.
• Ability to understand and interpret detailed policies and procedures.
• Demonstrates ability to work independently and react appropriately to changing job assignments.
• Demonstrates analytical, organizational, and problem-solving skills.
• Familiar with operating a PC and associated software.
• Demonstrated competency in Windows applications.
• Above average reading, writing, and arithmetic skills required.

Requirements

• Knowledge of benefit programs administered and/or supported by Capital BlueCross.
• Knowledge of CMS guidance and Medicare compliance obligations.
• Knowledge of customer service industry trends related to enhancing the beneficiary experience.
• A minimum of two years customer service or correspondence experience is required.
• High School degree and demonstrated work experience of no less than two years is required.
• Bachelor's degree in business administration, health care administration, or a related field is preferred.

Benefits

• Comprehensive benefits package including Medical, Dental & Vision coverage.
• Retirement Plan.
• Generous time off including Paid Time Off, Holidays, and Volunteer time off.
• Incentive Plan.
• Tuition Reimbursement.

Work Environment

• Sedentary work involving significant periods of sitting, talking, hearing, keying, and performing repetitive motions.
• Typical office conditions.

Physical Demands

• Frequently required to sit, use hands and fingers, talk, hear, and see.
• Must be able to work 37.5 hours per week.
• Occasionally lift and/or move up to 5 pounds.

Other

• Positions may be based in more than one on-site location.
• Some travel into the office on weekends may be required for training sessions and/or between buildings.