Senior Appeals Coordinator

Company :

Highmark Inc.

Job Description :

GENERAL OVERVIEW:

Conducts review of claims on services questioned on appeal by the provider or facility of the service, beneficiary, government program or other interested parties. Renders an independent decision based on research, and initiates a response to the inquirer and appropriate parties to the appeal in the form of an adjustment to payment, refund request for overpayment, or written correspondence when upholding the processing of service.

ESSENTIAL RESPONSIBILITIES:

Research and determine validity of inquiries identified as appeals received from members. Review additional documentation to determine if information needs to be forwarded to a clinician for additional consideration.

Render an independent decision based on research of the initial claim processing activity, documented procedures and policies, and information supplied with the appeal request.

Respond timely to inquiries that constitute an appeal or reopening of an initial claim determination, including generating written correspondence to the inquirer and other parties to the appeal.

Ensure members' appeal right are upheld and the corporate is in compliance with government guidelines.

Identify errors made during claims processing and follow procedures to initiate referrals and forward requests to appropriate units as necessary. Resolve adjustment claims which suspended.

Provide input to management regarding current inventory issues for inquiry analysis.

Review and apply new and updated procedures and guidelines. Identify quality-related problems and recommend process improvements.

Other duties as assigned or requested.

QUALIFICATIONS:

Minimum

• High School diploma or GED required for all levels

• 5-10 years of related, progressive experience.

Preferred

• None

Knowledge, Skills and Abilities

• Good verbal and written communication skills

• Solid customer service skills

• Ability to make independent decisions relating to claims processing accuracy

• Sound research and decision making to respond to inquiries

• Thorough knowledge of claims policies and benefits, processing instructions, as well as medical terminology

• Knowledge of processing systems

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees? No

WORK ENVIRONMENT

Is Travel Required? No

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.

Pay Range Minimum:

$20.31

Pay Range Maximum:

$30.12

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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 any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at [email protected]

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Req ID: J277283