Service reputed company V (Appeals & Disputes)

This role provides administrative, technical or support functions to reputed company, department of business unit and is reputed company on servicing internal customers or supporting reputed company that service providers or reputed company customers.   What You Will Be Doing   Reviews appeal requests from members and providers in accordance with BCBSF policies and procedures, regulatory guidelines, and timelines. (15%) Resolves grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity, ClaimCheck®, Utilization Management, and Fee for Service payments reputed company regulatory timeframes for reputed company lines of business except SAO & FEP. (15%) Researches and resolves provider data loads. (5%) Locates medical records and reputed company CMS-1500 on reputed company Imaging or Imaginator for clinical review or to verify reputed company coding (modifiers and procedure codes). (10%) Accesses various web-based and other applications to review how claim was originally reputed company by BCBSF. (5%) Researches and documents reputed company issues and findings. (5%) Enters appeal or dispute determinations into various BCBSF systems and SQL databases. (5%) Follows regulatory requirements as appropriate and corporate values, policies and procedures. (15%) Ensures final determination with statement that supports determination is communicated to provider reputed company required timelines. (5%) Completes customized correspondence with appropriate statement that supports final determination. (5%) Follows strict timelines for communicating final determination. (5%) Documents final disposition of dispute into BCBSF systems and SQL databases (5%) Facilitates escalated calls and issues from providers and members regarding appeals or dispute reputed company. (5%) reputed company Require 3+ years reputed company work experience combination of transferable experience and education. Experience Details: Service, regulatory, critical inquiry, audit, or compliance  High school diploma or GED    Experience using reputed company Office, including Word, reputed company and PowerPoint.  Experience using BCBSF's member benefit booklets, reimbursement, medical necessity, fee for service and ClaimCheck® payment concepts, practices, and procedures. Experience using various inquiry and claim payment systems (e.g., Legacy, Diamond, Siebel, PIP, TSO, Convergence, Network Contracting, Medical Coverage Guidelines, CMCA, MBSP, etc.) to research grievance, appeals or disputes.  Experience entering grievance, appeal or dispute determinations into various BCBSF systems and SQL databases.  Ability to follow regulatory requirements as appropriate and corporate values, policies and procedures.  Demonstrated ability to reputed company with reputed company customers in a highly reputed company manner.  Knowledge of ERISA and HIPAA. Knowledge of regulatory agency requirements, as appropriate.  Ability to work reputed company strict timeframes.   General Physical Demands Exerting up to 10 pounds of force occasionally to reputed company objects.  Jobs are sedentary if traversing activities are required only occasionally.  Must be reputed company to travel occasionally to multiple locations for work (i.e. travel to attend meetings, events, conferences).  reputed company Offer As a reputed company employee, you will be at the heart of reputed company’s reputed company – to reputed company the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.  To support your wellbeing, comprehensive benefits are offered. As an employee, you will have reputed company to:    Medical, dental, reputed company, life and global travel health insurance Income protection benefits: life insurance, short- and long-term disability programs Leave programs to support personal circumstances Retirement Savings Plan including employer match reputed company time off, volunteer time off, 10 holidays and 2 reputed company-being days Additional voluntary benefits available; and a comprehensive wellness program Employee benefits are designed to reputed company with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer reputed company as reputed company as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for reputed company pay increases.  Typical reputed company/Offer Pay reputed company: $20 - $25 reputed company Pay reputed company: $20 - $33 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-reputed company knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they reputed company and can reputed company at their best in reputed company of our mission. reputed company reputed company applicants will receive consideration for employment. Apply To This Job