Commercial A&G Res Specialist - Capital Blue Cross

Position Description:

The Shared Services Appeals Representative is responsible for identifying, reviewing and analyzing policy and procedure issues and providing recommendations for solutions. Ensures compliance with organizational and regulatory requirements. Appeals cover topics pertaining to enrollment, billing, benefits, and claims for various types of coverage offered by Capital BlueCross- Traditional, POS, PPO, HMO and Medicare Supplemental Programs. Knowledge of Medicare, PPACA, Healthy PA, CHIP, prescription, dental, vision, Chiropractic, Disease Management, Benefits Management, and other programs administered/supported by Capital BlueCross and Avalon.

Responsibilities and Qualifications:

Duties and Responsibilities:

• 20% - Researches and analyzes the customer's appeals. Determines appropriate action by reviewing and interpreting applicable policies/procedures that are within the established regulatory requirements. Utilizes the PC, manuals, online reference materials, Imaging, etc., to obtain benefits, enrollment and claim information.
• 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, Plus Billing and payment requests, Third Party Administrators, COBRA, reinstatements, conversions, refunds, new enrollment, transfer situations, student certifications, handicapped dependents, for all lines of business administered and supported by Capital BlueCross and Avalon. Conducts specific job related instructional sessions as requested by Supervisor.
• 15% - 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.
• 10% - Monitors appeals via utilizing various system generated reports for accurate and timely resolution to ensure customer satisfaction and compliance with MTM (Member Touchpoint Measures), PPACA, ERISA, and Act 68 quality, and timeliness guidelines.
• 10% - 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, 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 appeal trends to management that may indicate processing problems, lack of documentation or appropriate information concerning claims, enrollment areas, benefits, 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 BlueCross (e.g., open enrollment, on-site visits, etc.).
• - Performance standards, business metrics and process improvements to include: Complete ongoing training to stay abreast of product, service and policy changes. Improve our quality of work on a daily basis by learning and employing new skills. Recognize, document and alert the supervisor of trends in customer service inquiries. Conduct yourself in a manner consistent with the values of the organization.
• Researches and analyzes the customer's appeals. Determines appropriate action by reviewing and interpreting applicable policies/procedures that are within the established regulatory requirements. Utilizes the PC, manuals, online reference materials, Imaging, etc., to obtain benefits, enrollment and claim information.
• 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, Plus Billing and payment requests, Third Party Administrators, COBRA, reinstatements, conversions, refunds, new enrollment, transfer situations, student certifications, handicapped dependents, for all lines of business administered and supported by Capital BlueCross and Avalon. Conducts specific job related instructional sessions as requested by Supervisor.
• 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.
• Monitors appeals via utilizing various system generated reports for accurate and timely resolution to ensure customer satisfaction and compliance with MTM (Member Touchpoint Measures), PPACA, ERISA, and Act 68 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.
• Contacts the appropriate internal/external entities (e.g., groups, providers, Marketing, Legal, Host Plans, etc.) to obtain information and initiate necessary action.
• 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.
• Reports appeal trends to management that may indicate processing problems, lack of documentation or appropriate information concerning claims, enrollment areas, benefits, 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.
• 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 BlueCross (e.g., open enrollment, on-site visits, etc.).
• Performance standards, business metrics and process improvements to include: Complete ongoing training to stay abreast of product, service and policy changes. Improve our quality of work on a daily basis by learning and employing new skills. Recognize, document and alert the supervisor of trends in customer service inquiries. Conduct yourself 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 ERISA, Act 68, and BCBSA MTM,PPACA, HIPAA quality and timeliness guidelines and standards to ensure they are consistently met or exceeded
• Knowledge of Account Administration regulations, policies and procedures pertaining to Capital BlueCross and transfer of enrollment information to all our vendors
• Knowledge of multiple online inquiry and appeal systems and coding structures of files to interpret data used in responding to appeals.

Experience:

• A minimum of two years customer service or correspondence experience or experience/training in a writing-intensive role is required
• Experience with customer interaction preferred

Education and Certifications:

• High School degree and demonstrated work experience of no less than two years is required

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
• Travel@@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 diverse and 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.