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Appeals Analyst - MACBIC
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The incumbent participates in/presents case findings at weekly Horizon Member Appeals Committee Benefit Issues & Complaints (MACBIC) hearings. Incumbent will mentor more junior staff by responding to questions and sharing expertise.
* Appears before the Member Appeals Committee Benefit Issues & Complaints (MACBIC) at routinely scheduled hearings to present cases.
* At hearings, responsible for the comprehensive explanation of denials, the scope of coverage, and how the case was handled.
* At hearings, Responsible for addressing questions posed by the Member's representatives.
* Responsible for contacting all areas of the Company which handled the case in to facilitate fact gathering and to gain a thorough understanding of the benefit contract.
* Should issues addressed by the MACBIC be escalated to the DOBI or to the courts, the representative will be required to consult with outside attorneys or the DOBI as needed. May testify on behalf of Horizon BCBSNJ.
* Authorizes administrative exceptions which may involve claim adjustment resulting in payments at higher threshold levels so as to bring closure to the appeal; and, conducts daily image queue review to identify appeals and distributes other items as appropriate.
* Conducts detailed root cause analysis, including tracking and trending of errors and omissions that led to escalated complaint and makes recommendations to avoid future appeal occurrences .
* Identifies refresher/enhancement training opportunities for division and/or enterprise employees to reduce and/or eliminate appeals and administrative exceptions. Communicates opportunities to Quality and/or Training departments and works with Supervisors to share knowledge and provide guidance.
* Works with Quality and/or Training to develop and often deliver refresher training workshops to business teams on proper appeal handling.
* Represents Complaints/Appeals function on divisional and enterprise work groups. May be responsible to lead some such groups.
* Assists in the development of new/less experienced staff through mentoring, coaching and assisting them in the proper handling of appeal cases.
* Assists with running and validating reports for the team.
* Other duties as assigned.
* Bachelor's degree required. In lieu of degree applicant must have 5 years of equivalent and relevant work experience.
* Requires seven years of business experience which must include four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
* Healthcare industry experience required.
* Experience in complex claims processing necessary.
* Prior appeals handling experience preferred.
Additional licensing, certifications, registrations:
* Knowledge of HBCBSNJ complaints and appeals process preferred.
* Knowledge of insurance claim and membership systems required.
* Knowledge of medical terminology, COB, Medicare procedures required.
* Knowledge of UCSW preferred.
* Knowledge of Claims Policy guidelines required.
* Knowledge of Microsoft Office Suite required.
Skills and Abilities:
* The Employer may require an employee to pass a test(s) as a part of determining whether the applicant meets the minimum qualifications for the job.
* Requires keyboarding proficiency.
* Requires the ability to understand and use language correctly.
* Requires the ability to perform basic arithmetical calculations.
* Requires the ability to read, understand and interpret written materials.
* Requires the ability to apply reason in order to determine the appropriate arithmetical operation for solving a problem.
* Requires the ability to analyze information and to understand and apply rules and procedures.
* Requires the ability to compose business letters.
* Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder. Must be able to detail member/provider-specific issues through the development of individual correspondence for each case, explaining all issues in a comprehensive, understandable fashion.
* Excellent interpersonal skills (i.e. active listening).
* Strong research, investigative, analytical and problem solving skills.
* Ability to multitask.
* Ability to manage and diffuse irate callers.
* Time management skills.
Travel (If Applicable):
* Some travel may be required.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.
--Horizon NJ Health