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Medicare Appeals Analyst
Capital Blue CrossPosted 10/21/2026full-timeRemote • Pennsylvania • United StatesMid-LevelSenior💰 $49,300 - $92,885 per yearWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Appeals and Grievances processes, regulatory compliance, and operational analysis. Proficient in training development and implementation, with strong communication skills to support inter-departmental collaboration.
Highest-signal resume keywords
Appeals And Grievances ExperienceRegulatory Compliance KnowledgeFACETS Configuration ExpertiseMicrosoft Office Suite ProficiencyAnalytical Problem-Solving Skills
About the role
Key responsibilities & impact- Act as a central point of contact for staff within and outside Appeals and Grievances
- Provide analytical problem-solving support to Commercial and Medicare Appeals and Grievances staff
- Analyze operational policies, procedures, and performance metrics affecting the department
- Develop, implement, maintain, and monitor product and regulatory support
- Coordinate regulatory compliance activities, including assessing compliance and reviewing laws and regulations
- Research, analyze, recommend, and implement processing procedure changes
- Support training and documentation efforts
- Lead departmental process improvements and projects
- Represent the department on inter-departmental projects and major system enhancements
- Interpret and translate technical material for day-to-day appeals use
- Respond to inquiries from internal staff, other departments, and external business partners
- Research and resolve specialty inquiries and identified trends
- Research, evaluate, organize, and develop policies and procedures based on training needs
- Serve as subject matter expert on FACETS appeals module configuration and customer service inquiry module interaction
- Prepare training exercises and labs for new staff and refresher training
- Support regulatory and corporate compliance analysis, data validation, universe pulls, reporting, and data analysis
- Conduct peer reviews and document findings; provide audit support and mentoring
- Provide functional training for peers
- Evaluate performance metrics and communications from other departments and external vendors
- Assist with training programs and coordinate resources with training staff and management
- Promote approved company policies and procedures
- Provide technical support for PC and LAN systems, Windows, mainframe, Microsoft Office, Visual Basic macros, FACETS, PBM, and other systems
Requirements
What you’ll need- 3 years of Appeals and Grievances experience
- Advanced work experience with a PC and various software applications, including Microsoft Office Suite
- Bachelor's degree in business administration, health care administration, information systems or a related field, or equivalent demonstrated work experience of no less than three years
- High School degree and demonstrated work experience of no less than three years is required
- Comprehensive understanding of Capital Blue Cross benefit programs and products, Medicare and Commercial
- Knowledge of Federal and State regulatory requirements surrounding Appeals, including Medicare, Act 68, ERISA, HIPAA, and NCQA
- Strong oral and written communication skills
- Demonstrated competency in Windows, Outlook, Word, Internet Explorer, Excel, and PowerPoint
- Ability to navigate FACETS/Customer Service & Appeals modules
- Technical acumen to understand supporting configuration and business requirement development
- Knowledge of manual operations, policies, and procedures used throughout the Company
- Knowledge of appeals resolution processing procedures
- Ability to work independently and in groups, prioritize tasks, and adapt to changing workload requirements
- Ability to work 37.5 hours per week
Benefits
Comp & perks- Medical, Dental & Vision coverage
- Retirement Plan
- Paid Time Off
- Holidays
- Volunteer time off
- Incentive Plan
- Tuition Reimbursement
- Flexible environment
- Training and continuing education
- Community volunteering opportunities
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Regulatory Compliance AnalysisOperational Policy AnalysisAppeals Resolution ProcessingData ValidationPerformance Metrics EvaluationTechnical SupportTraining DevelopmentProcess ImprovementDocumentation SkillsPolicy Development
Soft Skills
Strong Oral CommunicationStrong Written CommunicationAbility To Work IndependentlyTeam CollaborationAdaptability
Tools & Technologies
FACETSMicrosoft OfficeWindowsOutlookExcelPowerPointVisual BasicMainframeLAN SystemsInternet Explorer
Industry Keywords
MedicareCommercial AppealsFederal RegulationsState RegulationsHIPAAERISANCQACapital Blue CrossAct 68Health Care Administration