This role provides administrative, technical or support functions to a team, department of business unit and is focused on servicing internal customers or supporting units that service providers or external customers.
- The essential functions listed represent the major duties of this role, additional duties may be assigned.
- Reviews appeal requests from members and providers in accordance with BCBSF policies and procedures, regulatory guidelines and timelines.
- Resolves grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity, ClaimCheck, Utilization Management, and Fee for Service payments within regulatory timeframes for all lines of business except SAO & FEP.
- Researches and resolves provider data loads.
- Locates medical records and form CMS-1500 on Enterprise Imaging or Imaginator for clinical review or to verify proper coding (modifiers and procedure codes).
- Accesses various web-based and other applications to review how claim was originally paid by BCBSF.
- Researches and documents all issues and findings.
- Enters appeal or dispute determinations into various BCBSF systems and SQL databases.
- Follows regulatory requirements as appropriate and corporate values, policies and procedures.
- Ensures final determination with statement that supports determination is communicated to provider within required timelines.
- Completes customized correspondence with appropriate statement that supports final determination.
- Follows strict timelines for communicating final determination.
- Documents final disposition of dispute into BCBSF systems and SQL databases
- Facilitates escalated calls and issues from providers and members regarding appeals or dispute decisions.
REQUIRED WORK EXPERIENCE
3+ years related work experience. Experience Details: Service, regulatory, critical inquiry, audit, or compliance
Experience using Microsoft Office, including Word, Excel and PowerPoint.
Experience using BCBSF's member benefit booklets, reimbursement, medical necessity, fee for service and ClaimCheck payment concepts, practices, and procedures.
Experience using various inquiry and claim payment systems (e.g., Legacy, Diamond, Siebel, PIP, TSO, Convergence, Network Contracting, Medical Coverage Guidelines, CMCA, MBSP, etc.) to research grievance, appeals or disputes.
Experience entering grievance, appeal or dispute determinations into various BCBSF systems and SQL databases.
Ability to follow regulatory requirements as appropriate and corporate values, policies and procedures.
Demonstrated ability to interact with internal and external customers in a highly professional manner.
Knowledge of ERISA and HIPAA.
Knowledge of regulatory agency requirements, as appropriate.
Ability to work within strict timeframes.
High school diploma or GED
GENERAL PHYSICAL DEMANDS
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Driving: Incidental Driving
We are an Equal Opportunity Employer/Protected Veteran/Disabled.