The Appeals Supervisor is responsible for all aspects of developing and maintaining a knowledgeable staff of Appeals Analysts who perform Appeals functions for the Health Advantage Appeals area. Researches collection and communications with inside and outside customers in an efficient, courteous and accurate manner.
EDUCATION
Bachelor’s degree in a related field. In lieu of degree, five (5) years’ relevant experience will be considered.
EXPERIENCE
Minimum five (5) years' customer-oriented experience in working primarily with escalated customer or provider issue OR applicable Masters in related field with minimum of three (3) years' experience.
Previous experience working as an employee of Health Advantage or its affiliates preferred. Prior experience should be at an exempt level with a minimum of three (3) years’ experience researching claims or benefit issues. The incumbent must have an extensive knowledge of benefits and enrollment regulations for Health Advantage, as well as a general understanding of all products and other classes of business sold by Arkansas Blue Cross Blue Shield.
Demonstrated success as an individual contributor in current or related operational/functional area. Exhibits ability to coach and train others; possesses organizational and planning skills. May have team leader experience.
Demonstrated proficiency in Microsoft® Office products with emphasis on Microsoft Word and database logic (Excel or Access). Visio Flow Chart experience and PowerPoint Presentation experience.
Experience dealing with medical issues preferred.
ESSENTIAL SKILLS & ABILITIES
Written & Verbal Communications
Time Management
Problem Solving
Demonstrated ability to utilize written communications for appeal responses.
Ability to understand medical terminology as it relates to the issues brought up in the appeal is necessary. Posses ability to understand medical terminology as it relates to issues.
Analyzes the situation and reports issues needing further investigation to the Manager when necessary. Reviews and responds to these calls as appropriate using his/her knowledge and professional skills to resolve the complaint when possible., Applies knowledge and understanding of all procedures related to Health Advantage ,  Adjustments, BlueCard Association Licensee Requirement Manual., Attends Arkansas Blue Cross and Blue Shield Blue Card Process Improvement meetings for the purpose of staying abreast of current issues facing the BlueCard area and making suggestions related to process and quality improvements., Develops and maintains a close working relationship with contacts in customer service, customer accounts, MARS,, the medical directors’ offices, government relations, etc., to ensure collecting complete, accurate information for use in appeals resolution., Develops the leadership skills necessary to oversee and improve employee understanding and incorporation of the values held by the Company., Handles all phone calls requiring communication with an irate/difficult customer, a physician, an attorney, or the Insurance Department., Keeps abreast of current and new provisions for all types of coverage issues related to Health Advantage., Maintains quality control by randomly reviewing response letters and files. Coaches and counsels subordinates in the appropriate measures to resolve inquiries., Participates in the URAC Appeals meeting with ABCBS Legal Appeals and the Corporate Medical Director to assure continued compliance with URAC guidelines and improvement in processes when appropriate., Regularly participates in meetings with the incumbent’s Manager  are held on a regular basis to review pertinent issues related to appeals., Supervises the hiring, coaching/training, employee development and performance management of assigned team. , Understands claims processing, adjustments, claim procedures, the enrollment processes, , etc., so direct reports can be pointed to the appropriate areas for information., Works with the BCBS Association and the Association Appeals Roundtable and shares ideas and suggestions with other plan appeal areas for the purpose of mutual quality improvement.
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Regular
ADA Requirements
1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.
