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Appeal Analyst
Arkansas Blue Cross and Blue Shield. Analyze and respond to inquiries, complaints and/or concerns from members, providers, regulatory bodies and/or attorneys .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in healthcare grievances, appeals, and claims processing while ensuring compliance with HIPAA and legal confidentiality standards. Proficient in analyzing and communicating medical coverage policies and appeal responses effectively.
Highest-signal resume keywords
Healthcare GrievancesClaims ProcessingMedical Coverage Policy CommunicationHIPAA ConfidentialityMicrosoft Office
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ResearchAppeals ManagementBenefit Plan KnowledgeMedical CodingAdministrative Record Maintenance
Soft Skills
Sound JudgementTaking Initiative
Tools & Technologies
Microsoft WordMicrosoft Excel
Industry Keywords
Legal ConfidentialityInsurance ProductsRegulatory ComplianceSegregation of Duties
About the role
Key responsibilities & impact- Analyze and respond to inquiries, complaints and/or concerns from members, providers, regulatory bodies and/or attorneys
- Communicate medical coverage policy, processing guidelines and policy language with internal and external sources to facilitate, resolve, and respond to appeals within URAC/legal timeframe
- Maintain administrative records of all case files, log appeals, and request relevant information from internal and external sources
- Maintain thorough knowledge of benefit plans
- Monitor the status of appeals
- Prepare written analysis communicating facts and determinations for appeal responses within the timeframe
- Recommend changes to the appeals process and contract language to minimize legal and regulatory liability
- Utilize current information from medical coding sources to ensure appeal guidelines are clear and concise
- Perform other duties as assigned
Requirements
What you’ll need- Bachelor’s degree in related field, or five (5) years' relevant experience in lieu of degree in addition to the listed experience requirements
- Minimum three (3) years' healthcare grievances, appeals, claims processing, claims research, customer service or related legal experience
- Working knowledge of insurance products, policies, procedures and/or claims processing preferred
- Experience using Microsoft Office, including Word and Excel
- Sound Judgement
- HIPAA Confidentiality
- Legal Confidentiality
- Taking Initiative
- Security and confidentiality of records and information
- Adherence to segregation of duties guidelines