QUALIFICATIONS:

Education Level: High School Diploma or GED.
Experience: 3 years experience in settings such as managed care, health care or insurance payor environment.

PREFERRED QUALIFICATIONS:

• Experience specifically working in Appeals and Grievances within a healthcare payor organization. College Degree.
• Knowledge of CareFirst system, Member/Provider Service, Claims or Care Management experience a plus.

KNOWLEDGE, SKILLS AND ABILITIES (KSAS)

• Knowledge and understanding of medical terminology.
• Demonstrated problem solving and decision-making skills, including the ability to exercise good judgement.
• Strong organizational and analytical skills.Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
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  Salary Range: $41,472 - $76,032
  Salary Range Disclaimer
  The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate’s work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case’s facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
  Department
  Clinical Appeals and Analysis
  Equal Employment Opportunity
  CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
  Where To Apply
  Please visit our website to apply: www.carefirst.com/careers
  Federal Disc/Physical Demand
  Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PURPOSE:

The Appeals Specialist I is responsible for the initial analysis of appeals and/or grievance correspondence, and determination of next steps for Commercial and Federal Employee Program lines of business. Responsible for collecting, organizing and tracking information to facilitate and expedite processing of appeals and/or grievances received from a variety of sources.

ESSENTIAL FUNCTIONS:

• Prioritize, research and analyze all pertinent information in preparation of an appeal and/or grievance request. Access the appropriate database to implement accurate and timely entry of appeal or reconsideration correspondence and updates the appropriate referral source communication system. Gathers all pertinent information and assigns cases to the nurse for further research, review and completion. Performs file coordination activities including, but not limited to filing of all active files, purging of files for transport to off-site storage.
• Utilizes professional written and verbal communications to assist in responses of all appeals and/or grievances based on State and Federal requirements for the particular line of business. Interacts regularly with and responds to internal and external stakeholders, without breaching confidentiality of medical information.
• Assists Supervisor and Appeals Specialist II and III with unit projects and other duties related to the appeals, grievance and reconsideration process. Communicates with Supervisor to offer feedback regarding continuous improvement of unit workflow and processes. Actively participates in monthly meetings and discussions regarding quality appeal and grievance research, data entry and to problem solve any issues regarding the appeal and/or grievance intake/entry process.