Gov't Programs Appeals & Grievances Specialist

Specialist The specialist is responsible for identifying, reviewing, and analyzing policy and procedure issues and providing recommendations for solutions. Ensures compliance with organizational, CMS, and other regulatory requirements. Appeals cover topics pertaining to enrollment, billing, benefits, and claims for various types of coverage offered under our PPO, HMO, Secure Rx, and Medicare Supplemental Programs. Knowledge of Medicare, CMS regulations, medical, prescription, dental, vision, chiropractic, disease management, benefits management, and other programs administered/supported by Capital BlueCross and Avalon. Responsibilities And Qualifications 20% - Researches and analyzes customer redetermination and reconsideration requests and provider appeals. Determines appropriate action by reviewing and interpreting applicable policies/procedures and CMS and HHS guidance that are within established regulatory requirements. Utilizes the PC, manuals, online reference materials, imaging technology, the appeals system, the PBM system to obtain benefits, enrollment, claims, and appeals case information. Appeal functions also include handling Medicare Part C and Part D grievances, case preparation for submission to the QIO (Quality Improvement Organization), case preparation for submission to the IRE (Independent Review Entity), and handling quality of service and quality of care complaints. Prepares case files and attends administrative law hearings, when required. 20% - Ensures the satisfactory resolution of routine and complex appeals including, but not limited to, benefits, claim filing and processing, collection issues, enrollment discrepancies, legal requests, Medicare Secondary Payer, billing and payment requests, reinstatements, conversions, refunds, new enrollment, transfer situations, disability certifications, handicapped dependents, for all lines of Medicare Part C and Part D business administered and supported by Capital BlueCross and Avalon. 15% - Conducts specific job-related instructional sessions as requested by management in accordance with CMS and HHS guidance. 10% - Respond to customers appeals via telephone, correspondence, on-site, Fax, Secure IT, E-mail, and personal interviews from individual customers, group administrators, providers, Capital BlueCross personnel, Host Plan personnel, attorneys, and outside entities working on the customer's behalf. Interacts with the PBM and the IRE to resolve cases. 10% - Monitors appeals via utilizing various system-generated reports for accurate and timely resolution to ensure customer satisfaction and compliance with all applicable quality, and timeliness guidelines. Provides clear and concise instructions to the appropriate Plan area, in the approved format (e.g., electronic, on-line or hard copy forms, telephone contact) for the resolution of the issues. 5% - Contacts the appropriate internal/external entities (e.g., groups, providers, Marketing, Legal, Host Plans, PBM, IRE, QIO, ALJ, CMS, etc.) to obtain information and initiate necessary action. 5% - Enters all information necessary to update the Facets appeal module, or Work Desk when appropriate, for tracking appeals action and status. Utilizes the system to obtain background information and prevent duplication of effort. 5% - Reports to management appeal trends that may indicate processing problems, lack of documentation or appropriate information, including but not limited to, claims, enrollment areas, benefits, pharmacy services, policies, and procedures. Additionally, the incumbent may: Conduct peer reviews and document findings as assigned. Provide audit support. Provide desk mentoring for new staff and staff undergoing cross-training. Provide functional training for peers, as required by workload. 5% - Assists/participates with Marketing personnel and the broker community in the support of customer needs by researching and communicating information to other Company personnel or directly to the customer. May attend or participate in marketing-related activities as a representative of Capital Blue Cross (e.g., open enrollment, on-site visits, etc.). 5% - Performance standards, business metrics, and process improvements to include: Complete all CMS required acknowledgements related to training and coaching. Complete ongoing training to stay abreast of product, service, and policy changes. Improve quality of work on a daily basis by learning and employing new skills. Recognize, document, and alert management of trends in customer service inquiries and appeals. Conducts oneself in a manner consistent with the values of the organization. Skills Demonstrates ability to communicate effectively and professionally both verbally and in writing with all levels of internal/external personnel in order to respond to customer inquiries ranging from routine to complex and involving sensitive subject matter. Demonstrates ability to understand and interpret detailed policies and procedures and to be able to apply them to various situations. This includes thorough understanding of CBC's responsibility to maintain privacy of Protected Health Information as required by the Health Insurance Portability and Accountability Act. Demonstrates ability to work independently, be flexible, and react appropriately to changing job assignments and work environments. Demonstrates analytical, organizational, and problem-solving skills in order to accurately and efficiently identify, analyze, and respond to customer/provider appeals, as well as identify and analyze trends and discrepancies. Familiar with, or ability to, operate a PC and associated software; Microsoft Word, Excel, etc., phone equipment, calculator, fax, copier, and other department required hardware. Demonstrated competency in Windows (Outlook, Word, Internet Explorer, Excel, and PowerPoint) Above average reading, writing, and arithmetic skills required (reading/math comprehension) Knowledge Knowledge of benefit programs administered and/or supported by Capital BlueCross. Includes Medicare Advantage, Medicare Part D and Medicare Supplemental Programs, Dental, Vision, Chiropractic, Prescription Drug, Benefits Management, and Disease Management. Knowledge of the PBM and Facets health plan administration processing systems as well as online files for determining enrollment, billing, and benefits. Knowledge of benefits administration policies, customer billing processes, claims processing, and general procedures. Knowledge of CMS guidance, in particular, Chapter 6 (formulary), Chapter 13, and Chapter 18 appeals regulations and processes. Knowledge of Medicare compliance obligations Knowledge of Medicare marketing and sales regulations and obligations Knowledge of NCQA, BCBSA MTM, and HIPAA quality and timeliness guidelines and standards to ensure they are consistently met or exceeded. Knowledge of multiple online inquiry and appeal systems and coding structures of files to interpret data used in responding to appeals. Knowledge of systems used to support the Medicare enrollment exchange processes including CMS regulations, policies, and procedures pertaining to Capital BlueCross, Avalon, and transfer of enrollment to all applicable vendors. Awareness of customer service industry trends related to enhancing the beneficiary experience Experience A minimum of two years customer service or correspondence experience or experience/training in a writing-intensive role is required Extensive experience with customer interaction preferred Education And Certifications High School degree and demonstrated work experience of no less than two years is required Bachelors degree in business administration, health care administration, or a related field or equivalent demonstrated work experience of no less than two years Work Environment Sedentary work involving significant periods of sitting, talking, hearing, keying, and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor. Working environment includes typical office conditions. Physical Demands While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work 37.5 hours per week. The employee must occasionally lift and/or move up to 5 pounds. Other Positions may be based in more than one on-site location Some travel into the office on weekends may be required for training sessions and/or between buildings. About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital, you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Created: 2026-03-04