Supervisor Appeals & Correspondence

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Applicants must be eligible to begin work on the date of hire. Applicants must be currently authorized to work in the United States on a full-time basis. ARKANSAS BLUE CROSS BLUE SHIELD will NOT sponsor applicants for work visas in this position.Arkansas Blue Cross is only seeking applicants for remote positions from the following states:Arkansas, Florida, Georgia, Illinois, Kansas, Louisiana, Minnesota, Mississippi, Oklahoma, South Carolina, Tennessee, Texas, Virginia and Wisconsin.

Job SummaryThe Supervisor Appeals & Correspondence is responsible for all aspects of developing and maintaining a knowledgeable staff of Legal Researchers who perform research functions for the Legal Appeals area. Research collection and communications with inside and outside customers must be performed in an efficient, courteous and accurate manner. This position must also ensure compliance with state and federal regulations and laws related to appeal response requirements and deadlines for response. This position prepares monthly appeal reports used for internal and external reporting. These reports are used to follow trends for potential quality improvements to be identified. The Appeals Supervisor will also act as an Appeals Analyst and respond to appeals based upon direction from the Senior Counsel Appeals and the RN Appeals.

Requirements

EDUCATION

Bachelor's degree in a related field. In lieu of degree, five (5) years' experience as an Appeals Analyst will be considered.

EXPERIENCE

Minimum five (5) years' customer-oriented experience in working primarily with escalated customer or provider issues, or as an Appeals Analyst. OR applicable Masters in related field with minimum three (3) years' experience.

Minimum two (2) years’ experience utilizing Microsoft Word and Excel.

Demonstrated success as an individual contributor in current or related operational/functional area. Exhibits ability to coach and train others; possesses organizational and planning skills. May have team leader experience.

Demonstrated knowledge of Microsoft® Office products with emphasis on Microsoft Word and database logic (Excel or Access). Visio Flow Chart experience and PowerPoint Presentation experience.

Detailed knowledge of coverage and enrollment issues related to BlueCard. The position must be familiar with all procedures related to BlueCard Home and Host Processing, Home and Host Adjustments, BlueCard Association Licensee Requirement Manual.

Thorough knowledge of all coverage, products, and other classes of business sold by Arkansas Blue Cross Blue Shield.

Experience with medical issues preferred.

ESSENTIAL SKILLS & ABILITIES

Oral & Written Communication

Interpersonal

Problem Solving

Ability to understand medical terminology as it relates to the issues brought up in the appeal is necessary.

Ability to effectively communicate the specific legal issues related to an appeal and be able to explain how a specific Medical Coverage Policy, a processing guideline or the member’s policy language applies to an appeal.

All applicants must complete the Supervisory Assessment Center.

Skills

ResponsibilitiesAudits the Appeals Researchers files to ensure appropriate follow up, accuracy of information and correct use of grammar and punctuality. Meets with Appeals Researchers one on one to address inaccuracies. This must be done in a non-judgmental manner and should be presented as a learning opportunity., Demonstrates reliability in work attendance and job performance and use of appropriate discretion in maintaining confidentiality of all company information, including any sensitive proprietary or legal information., Ensures inquiries from displeased customers, physicians, attorneys, or the Insurance Department are answered accurately and timely. Analyzes the situation and reports issues needing further investigation to the Senior Counsel Appeals when necessary., Knowledgeable of ABCBS benefits and policies while providing input on accuracy and professionalism of these., Organizes workflow for maximum efficiency and effectiveness and to function independently in the absence of the Sr. Counsel of Appeals. Make decisions, renders judgments, takes action and assumes responsibility for those decisions., Participates in the URAC Appeals meeting with Health Advantage and the Corporate Medical Director to assure continued compliance with URAC guidelines and improvement in processes when appropriate., Proposes and develops creative solutions to complaint and appeal related issues that affect providers and members., Provides assistance in the development of goals and objectives for this position., Provides prompt responses to requests from other areas of the Enterprise for data related to their particular location or line of business., Sorts data for quarterly and yearly reports for submission to management with appropriate documentation. Appropriate data will be presented in accepted qualify management format., Stays abreast of current issues facing the BlueCard area and makes suggestions related to process and quality improvements., Supervises the hiring, coaching/training, employee development and performance management of Legal Appeals team. , Utilizes information gained from processes to recommend improvements to department. Works with Sr. Counsel Appeals to upgrade existing Policies and Procedures and implement improvements., Works with Sr. Counsel Appeals to ensure that all regulatory requirements of the complaint and appeal process have been met. This includes the submission of External Review requests to the IRO (Independent Review Organization), and providing reports to the Arkansas Insurance Department.

Certifications

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment TypeRegular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.